A retrospective for perioperative outcomes of the subxiphoid video-assisted thoracic surgery thymectomy in non-myasthenia thymoma

A retrospective for perioperative outcomes of the subxiphoid video-assisted thoracic surgery thymectomy in non-myasthenia thymoma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A retrospective for perioperative outcomes of the subxiphoid video-assisted thoracic surgery thymectomy in non-myasthenia thymoma zipu yu, Lian Wang, Ling Zhu, Bingqiang Gao, Gang Shen, Guofei Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7943944/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective Minimally invasive approaches are widespreadly being applied via different routes for thymoma. The present study aimed to assess the perioperative outcomes of the subxiphoid approach in video-assisted thoracic surgery (VATS) thymectomy for non-myasthenia thymoma patients in our group. Methods Patients who underwent VATS thymectomy via subxiphoid approach between 2020 and 2023 were retrospectively analyzed in our medical group. 41 patients were finally included for peri-operative outcomes analysis. Results There was 1 conversion to median sternotomy owing to inominate vein injury and hemorrhage (≥ 300ml). All patients achieved a good recovery after surgery, and none had serious complications. There were no perioperative deaths. 10 patients underwent post-operative adjuvant radiotherapy. 10 patients refused to receive post-operative adjuvant radiotherapy. CONCLUSION With the subxiphoid incision as the operating port, the subxiphoid VATS thymectomy could provide satisfactory therapeutic effect when an auxiliary sternal retractor is needed (diameter of thymoma ≥ 5cm). This method has significant advantage in reducing postoperative acute phase pain. Thymectomy Thymoma Subxiphoid approach Video-assisted thoracic surgery Sternal retractor Figures Figure 1 Figure 2 Figure 3 Introduction The most common tumor type in the anterior mediastinum is thymoma, accounting for approximately 19–42% of mediastinal tumors( 1 , 2 ). Most patients are asymptomatic( 3 ). In order to reflect tumors’ biological behavior and clinical prognosis, the thymic epithelial neoplasms are classified into types A, AB, B1, B2, B3, and C by World Health Organization (WHO) in 2015. Consequently, tissue type is simplified into three subtypes: low-risk group (types A, AB, and B1), high-risk group (types B2 and B3), and thymic carcinoma group (type C). Transsternal or transthoracic thymectomy is the gold standard treatment for patients with thymoma( 4 – 6 ). However, thoracoscopic thymectomy is gradually being chosen with the development of minimally invasive thoracoscopic techniques. The advantages include its less intraoperative bleeding and damage, less postoperative pain and complications. Video-assisted thoracoscopic surgery (VATS) is the preferred option( 7 ). There are several minimally invasive thymectomy approaches available, including VATS thymectomy with a intercostal approach (IVATS), and VATS thymectomy with a subxiphoid approach (SVATS)( 8 , 9 ). Thymectomy via the subxiphoid approach has been used successfully in our group during past four-year clinical practice. We conducted this retrospective study to evaluate the perioperative outcomes of SVATS for thymoma in our group from January 2020 and December 2023. MATERIALS AND METHODS 1. Patients From January 2020 to December 2023, 41 patients with non-myasthenia thymoma underwent subxiphoid thoracoscopic thymectomy in our group in the Thoracic Surgery Department of the Second Affiliated Hospital of Zhejiang University. This study was authorized by the Ethics Committee of the Second Affiliated Hospital of Zhejiang University. (2024 − 0463) 2. Surgical technique and subxiphoid-approach thoracoscopic thymectomy (SATT) modification. The surgical approach was determined by the tumor location and the surgeon’s habits. The subxiphoid-approach thoracoscopic thymectomy (SATT) approach was included in this study. The enhanced CT/MRI was used for thymoma identification. The surgical resection scope included all adipose tissue between the two phrenic nerves in the anterior mediastinum, and the upper poles and lower poles of the thymus. With the help of a strong specimen bag, the resected specimens were removed through the subxiphoid port. The subxiphoid port was enlarged in accordance with the specimen size. An auxiliary sternal retractor was used according to the specimen size (diameter ≥ 5cm). Almost 1–2 cm below the lower edge of the xiphoid, a 3-cm vertical port was made as the operating pole for ultrasound knife. Two small incisions were made at the overlap of bilateral costal arch and clavicle midline as the auxiliary operating hole (right port) and observation port (left port) for insertion of surgical instruments and thoracoscope. A vertical 2.0 cm incision was made at the right or left third intercostal parasternal position for insertion of a sternal retractor for thoracic volume enlargement if necessary(diameter ≥ 5cm). A pneumomediastinum was created by a 8 cm H 2 O positive pressure carbon dioxide (CO2) insufflation. 3. Postoperative management The majority tracheal intubation of patients was extubated immediately postoperatively. For pain management, an analgesic regimen was used. Postoperative pain scores at 24 hours, 48 hours after the operation and 3 days after the discharge were assessed. The chest tube was removed when drainage was less than 200 ml/day with no air leakage and an acceptable range for the drainage fluid color. Patients who were able to mobilize independently were discharged after chest tube removal, with a moderate VAS assessment and achievement for discharge standards. 4. Statistical analysis Demographic characteristics and clinical data were collected through electronic medical records. Continuous variables were expressed as the mean ± standard deviation. The chi-square test was used to compare categorical variables, and the t-test was used to compare continuous variables. The p-value<0.05 was considered statistically significant. Statistical analysis was conducted using SPSS version 20.0 (SPSS Inc., Chicago, IL, USA). RESULTS 1. Patient characteristics. The screening flowchart is shown in Fig. 1 . A total of 41 cases were enrolled in this study. The baseline clinical data of the patients were summarized in Table 1. 2. Perioperative outcome and conversions 2. Perioperative outcome and conversions No patient underwent other treatment before surgery. The procedure was performed from the subxiphoid pathway with an auxiliary sternal retractor in patients (diameter ≥ 5cm) Fig. 2 . The median tumor size was 46.01 ± 22.56 mm, and the maximal tumor size was 90 mm. The median operation time was 110.88 ± 33.49 minutes. The median blood loss was 24.27 ± 33.22 ml. The median hospital stay was 2.32 ± 1.06 days. There was one conversion to median sternotomy owing to inominate vein injury and hemorrhage (≥ 300ml). The perioperative data of the patients were summarized in Table 2. 3. Morbidity and mortality. The total postoperative complication rate was 0% (0/41). No 30-day readmissions or perioperative deaths occurred. The classification of thymoma were summarized in Table 3. 4. Postoperative additional treatment. There are a total of 20 patients with thymoma type B2 and beyond. Additional treatment after surgery for these 20 patients were detailed in the Table 4. 5. Postoperative Visual analog pain scores (VSA) and follow-up. Postoperative pain scores at 24 hours, 48 hours and 3 days after the discharge were assessed. The VAS scores in the group were (6.24 ± 0.89) on the post-operative day (POD) 1, (5.12 ± 0.75) on the POD 2, and (2.20 ± 0.51) 3 days after the discharge. The postoperative VAS scores of the patients were summarized in Fig. 3 . DISCUSSION According to the National Comprehensive Cancer Network (NCCN) guidelines, thoracoscopic thymectomy could be applied to treat Masaoka-Koga stages 1 and 2 thymoma for patients without myasthenia gravis( 10 )(Table 5). Thymectomy is considered as the cornerstone treatment for thymoma. Owing to its superior oncological results, transsternal thymectomy is considered to be the gold standard( 4 , 5 ). During recent years, minimal invasive techniques have been accepted as an alternative approach for its advantages and equivalent efficacy. This surgical method could not only ensure complete tumor resection, but also have the preponderance of avoiding the median sternotomy.( 9 , 11 , 12 ) Various approaches have been developed, including unilateral, bilateral, subxiphoid single-port, and intercostal approaches( 13 – 18 ). The complete surgical resection in non-myasthenia gravis (MG) patients is the key ingredient for thymomas( 19 ). Proponents of complete thymectomy insist on extensive thymectomy including the thymus and the anterior mediastinal adipose tissues resecting ( 20 , 21 ). However, the necessity of removing the whole thymus gland has been questioned for thymomas without MG ( 22 ). Recurrence rates were not significantly higher after thymomectomy alone in thymomas patients ( 23 , 24 ). Our recommendation is to perform a complete thymectomy. There are two most important principles in the surgical treatment. One of these is the necessity of removal the whole thymus gland. The other rule is the need of performance of thymectomy with removal of the adipose tissue in the anterior mediastinum. In 1999, Akamine et al. reported a case by VATS subxiphoid approach( 25 ). This approach allows surgeons to visualize both phrenic nerves and reach high into the anterior mediastinum. It could provide a unique advantage of simultaneous bilateral access to the pleural cavities. In addition, with the support of using CO2 and retractors, the surgical field and exposure the upper mediastinum could be superiorly acquired ( 13 , 26 , 27 ). The cephalic-brachial vein and its connection with the superior vena could be more clearly exposure under surgical field of view. For the thymoma patients, we followed the principles published by the International Thymic Malignancy Interest Group: resection of thymoma and tissue; dissection and visualization surrounding the innominate vein; removal of the specimen in a specimen bag; and completeness examination( 19 , 28 ). Multiportal or uniportal subxiphoid thymectomy approaches were reported ( 9 , 29 , 30 ). However, large thymic tumors should be limited due to the inadequate surgical manipulability and limited space. We suggest that the procedure could be performed with an auxiliary sternal retractor in patients (diameter ≥ 5cm). A vertical port below the lower edge of the xiphoid was made as the operating pole for ultrasound knife. The two additional small subcostal incisions could avoid interference among the surgical instruments and make the surgical procedure unhindered. In our group, the xiphoid port was made as the main operating hole. The right subcostal incision was made as the accessory operating hole, with the left subcostal incisions as the observational hole. There were several advantages for this approach: 1) During surgery, the patient could be in a supine position to avoid special requirements. 2) The surgical doctors would have good operating space, avoiding instrument interference. 3) Our approach could provide a unique advantage of simultaneous bilateral access to the pleural cavities for ultrasound knife. Postoperative pain scores at 24 hours, 48 hours and 3 days after the discharge were assessed. The VAS scores in the group were low on the POD 1 (6.24 ± 0.89), POD 2 (5.12 ± 0.75), and 3 days after the discharge (2.20 ± 0.51). This xiphoid process method has significant advantages in reducing postoperative pain by the incision avoidance of the chest ribs. There were several advantages for this subxiphoid and subcostal arch approach. Firstly, the anterior mediastinum could be well exposed and three ports facilitated the operation. Secondly, the intercostals nerves compression or injury could be avoided. Thirdly, no separate ventilation was needed. Fourthly, the ultrasound knife in the main operating hole could have a larger operating space for both sides of the chest cavity. Conclusion With the subxiphoid incision as the operating port and an auxiliary sternal retractor, the subxiphoid VATS thymectomy could provide satisfactory therapeutic effect. Subxiphoid video-assisted thoracic surgery has potential advantages of a less postoperative VAS score. Owing to a limited number of cases, further prospective studies are needed to comfirm this favorable effect. Limitation The present study has several limitations: 1) a retrospective study, 2) a single-group experience in single-center, 3) a small number of cases inclued. 4) without a long-term follow-up period. 5) absence of the comparative analysis group, leading to the incomplete persuasiveness of the research results. Abbreviations video-assisted thoracic surgery (VATS) World Health Organization (WHO) intercostal video-assisted thoracic surgery (IVATS) subxiphoid video-assisted thoracic surgery (SVATS) subxiphoid-approach thoracoscopic thymectomy (SATT) Visual analog pain scores (VSA) post-operative day (POD) National Comprehensive Cancer Network (NCCN) myasthenia gravis (MG) Declarations Clinical trial number: not applicable Acknowledgements We acknowledge all members of Department of Thoracic Surgery, 2 nd Affiliated Hospital, Zhejiang University, Hangzhou, China for their support. We thank all the group members for their helpful discussions for our paper. Funding Not applicable. Competing interests The authors declare that they have no competing interests Authors’ contributions ZPY participated in all aspects of the experiment and drafted the article. All authors read and approved the final manuscript. Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Consent to publish All informed consents were obtained from all participants or from guardians. Consent to participate Not applicable. This is a retrospective study. Ethics statement This study was reviewed and approved by the Ethics Committee of the Second Affiliated Hospital of Zhejiang University. The research involved no more than minimal risk to the participants. This study was retrospective data analysis of previously collected medical records (2024-0463). All research procedures were conducted in accordance with the ethical standards of the the Ethics Committee of the Second Affiliated Hospital of Zhejiang University, ensuring compliance throughout the study. References Kondo K. Therapy for thymic epithelial tumors. Gen Thorac Cardiovasc Surg 2014;62:468-474. Lo Iacono G, Gigli F, Gherzi L, Avenoso D, Fiori S, Sedda G, Tarella C, et al. Thymoma and pure red cell aplasia with hypoplasia of megakaryocytopoiesis: A rare and life-treating condition. Transfus Apher Sci 2020;59:102656. Kelly RJ, Petrini I, Rajan A, Wang Y, Giaccone G. Thymic malignancies: from clinical management to targeted therapies. J Clin Oncol 2011;29:4820-4827. Davenport E, Malthaner RA. The role of surgery in the management of thymoma: a systematic review. Ann Thorac Surg 2008;86:673-684. Friedant AJ, Handorf EA, Su S, Scott WJ. Minimally Invasive versus Open Thymectomy for Thymic Malignancies: Systematic Review and Meta-Analysis. J Thorac Oncol 2016;11:30-38. 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Tables Table 1 The baseline clinical data of the patients (N=41) Indicator Group Result Sex male 21(51.22%) female 20(48.78%) Age 54.90±11.92 BMI 23.40±2.87 ASA grading I 18(43.9%) II 14(34.15%) III 9(21.95%) Table 2 The perioperative indicators data of the patients (N=41) Indicator Group Result Operative time(min) 110.88±33.49 Blood loss(ml) 24.27±33.22 Length of stay(days) 3.59±2.26 Drainage volume(ml) 7.51±7.59 Extubation Yes No 41(100%) 0(0%) Conversion Yes 1(2.44%) No 40(97.56%) Table 3 The morbidity and mortality data of the patients were summarized (N=41) Indicator Group Result Type A 4(9.76%) AB 12(29.27%) B1 3(7.32%) B1/B2 2(4.88%) B2/B3 3(7.32%) B2 8(19.51%) B3 2(4.88%) C 7(17.07%) Size(mm) 46.01±22.56 Complication No 41(100%) Table 4. Additional treatment after surgery (N=20) Type B2 B2/ B3 B3 C Total Thymoma 8 3 2 7 20 Additional treatment 1 2 1 6 10 Declining Additional treatment 7 1 1 1 10 Table 5. Masaoka–Koga staging system. Installments Performance Phase I The envelope was complete and no tumor cells invaded the envelope Phase II a Microscopically, the tumor cells invaded the envelope Phase II b Tumor cells infiltrated into the pleural or adipose tissue Phase III Tumor cells invaded adjacent organs such as the lungs, pericardium, large blood vessels, and more Phase IVa The tumor occurred with implant metastases to the pleural or pericardium Phase IVb Tumor cell metastases through the lymphatic tract or blood, with distant metastasis Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7943944","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":561089944,"identity":"bf085598-aca1-4b6b-8918-b2155694773d","order_by":0,"name":"zipu yu","email":"","orcid":"","institution":"Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"zipu","middleName":"","lastName":"yu","suffix":""},{"id":561089945,"identity":"ee3f3bb0-5fe7-40d4-9e42-7e876a71e60f","order_by":1,"name":"Lian Wang","email":"","orcid":"","institution":"Zhejiang 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1","display":"","copyAsset":false,"role":"figure","size":36943,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart summarizing patient enrolment in this study.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7943944/v1/b2d095fdd37343984edec587.jpg"},{"id":98777935,"identity":"10b0b523-a5e9-41d6-8140-3d0da87a83bb","added_by":"auto","created_at":"2025-12-22 12:28:41","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":822252,"visible":true,"origin":"","legend":"\u003cp\u003eThe procedure insertion of surgical instruments and an auxiliary sternal retractor for the subxiphoid pathway procedure.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7943944/v1/92d23537663ac2ef7b267dc4.jpg"},{"id":98777642,"identity":"ffe1c5ee-14e2-44ec-ab75-52d8e9d6e339","added_by":"auto","created_at":"2025-12-22 12:28:15","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":29110,"visible":true,"origin":"","legend":"\u003cp\u003eThe postoperative VAS scores of the patients in this study.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7943944/v1/3e32e105c7c43b48acf03f79.jpg"},{"id":102398455,"identity":"63943d8c-22ba-48fb-8b91-8e845bea7e27","added_by":"auto","created_at":"2026-02-11 10:22:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1549916,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7943944/v1/f288ad2c-1b48-4d6b-8a5f-1b306e1dc68d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A retrospective for perioperative outcomes of the subxiphoid video-assisted thoracic surgery thymectomy in non-myasthenia thymoma","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe most common tumor type in the anterior mediastinum is thymoma, accounting for approximately 19\u0026ndash;42% of mediastinal tumors(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Most patients are asymptomatic(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In order to reflect tumors\u0026rsquo; biological behavior and clinical prognosis, the thymic epithelial neoplasms are classified into types A, AB, B1, B2, B3, and C by World Health Organization (WHO) in 2015. Consequently, tissue type is simplified into three subtypes: low-risk group (types A, AB, and B1), high-risk group (types B2 and B3), and thymic carcinoma group (type C).\u003c/p\u003e \u003cp\u003eTranssternal or transthoracic thymectomy is the gold standard treatment for patients with thymoma(\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). However, thoracoscopic thymectomy is gradually being chosen with the development of minimally invasive thoracoscopic techniques. The advantages include its less intraoperative bleeding and damage, less postoperative pain and complications. Video-assisted thoracoscopic surgery (VATS) is the preferred option(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). There are several minimally invasive thymectomy approaches available, including VATS thymectomy with a intercostal approach (IVATS), and VATS thymectomy with a subxiphoid approach (SVATS)(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThymectomy via the subxiphoid approach has been used successfully in our group during past four-year clinical practice. We conducted this retrospective study to evaluate the perioperative outcomes of SVATS for thymoma in our group from January 2020 and December 2023.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\n\u003ch3\u003e1. Patients\u003c/h3\u003e\n\u003cp\u003eFrom January 2020 to December 2023, 41 patients with non-myasthenia thymoma underwent subxiphoid thoracoscopic thymectomy in our group in the Thoracic Surgery Department of the Second Affiliated Hospital of Zhejiang University. This study was authorized by the Ethics Committee of the Second Affiliated Hospital of Zhejiang University. (2024\u0026thinsp;\u0026minus;\u0026thinsp;0463)\u003c/p\u003e\n\u003ch3\u003e2. Surgical technique and subxiphoid-approach thoracoscopic thymectomy (SATT) modification.\u003c/h3\u003e\n\u003cp\u003eThe surgical approach was determined by the tumor location and the surgeon\u0026rsquo;s habits. The subxiphoid-approach thoracoscopic thymectomy (SATT) approach was included in this study. The enhanced CT/MRI was used for thymoma identification.\u003c/p\u003e \u003cp\u003eThe surgical resection scope included all adipose tissue between the two phrenic nerves in the anterior mediastinum, and the upper poles and lower poles of the thymus. With the help of a strong specimen bag, the resected specimens were removed through the subxiphoid port. The subxiphoid port was enlarged in accordance with the specimen size. An auxiliary sternal retractor was used according to the specimen size (diameter\u0026thinsp;\u0026ge;\u0026thinsp;5cm).\u003c/p\u003e \u003cp\u003eAlmost 1\u0026ndash;2 cm below the lower edge of the xiphoid, a 3-cm vertical port was made as the operating pole for ultrasound knife. Two small incisions were made at the overlap of bilateral costal arch and clavicle midline as the auxiliary operating hole (right port) and observation port (left port) for insertion of surgical instruments and thoracoscope. A vertical 2.0 cm incision was made at the right or left third intercostal parasternal position for insertion of a sternal retractor for thoracic volume enlargement if necessary(diameter\u0026thinsp;\u0026ge;\u0026thinsp;5cm). A pneumomediastinum was created by a 8 cm H\u003csub\u003e2\u003c/sub\u003eO positive pressure carbon dioxide (CO2) insufflation.\u003c/p\u003e\n\u003ch3\u003e3. Postoperative management\u003c/h3\u003e\n\u003cp\u003eThe majority tracheal intubation of patients was extubated immediately postoperatively. For pain management, an analgesic regimen was used. Postoperative pain scores at 24 hours, 48 hours after the operation and 3 days after the discharge were assessed. The chest tube was removed when drainage was less than 200 ml/day with no air leakage and an acceptable range for the drainage fluid color. Patients who were able to mobilize independently were discharged after chest tube removal, with a moderate VAS assessment and achievement for discharge standards.\u003c/p\u003e\n\u003ch3\u003e4. Statistical analysis\u003c/h3\u003e\n\u003cp\u003eDemographic characteristics and clinical data were collected through electronic medical records. Continuous variables were expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. The chi-square test was used to compare categorical variables, and the t-test was used to compare continuous variables. The p-value\u0026lt;0.05 was considered statistically significant. Statistical analysis was conducted using SPSS version 20.0 (SPSS Inc., Chicago, IL, USA).\u003c/p\u003e"},{"header":"RESULTS","content":"\n\u003ch3\u003e1. Patient characteristics.\u003c/h3\u003e\n\u003cp\u003eThe screening flowchart is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A total of 41 cases were enrolled in this study. The baseline clinical data of the patients were summarized in Table\u0026nbsp;1.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003e2. Perioperative outcome and conversions\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003e2. Perioperative outcome and conversions\u003c/div\u003e \u003cp\u003eNo patient underwent other treatment before surgery. The procedure was performed from the subxiphoid pathway with an auxiliary sternal retractor in patients (diameter\u0026thinsp;\u0026ge;\u0026thinsp;5cm) Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The median tumor size was 46.01\u0026thinsp;\u0026plusmn;\u0026thinsp;22.56 mm, and the maximal tumor size was 90 mm. The median operation time was 110.88\u0026thinsp;\u0026plusmn;\u0026thinsp;33.49 minutes. The median blood loss was 24.27\u0026thinsp;\u0026plusmn;\u0026thinsp;33.22 ml. The median hospital stay was 2.32\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06 days.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThere was one conversion to median sternotomy owing to inominate vein injury and hemorrhage (\u0026ge;\u0026thinsp;300ml). The perioperative data of the patients were summarized in Table\u0026nbsp;2.\u003c/p\u003e\n\u003ch3\u003e3. Morbidity and mortality.\u003c/h3\u003e\n\u003cp\u003eThe total postoperative complication rate was 0% (0/41). No 30-day readmissions or perioperative deaths occurred. The classification of thymoma were summarized in Table\u0026nbsp;3.\u003c/p\u003e\n\u003ch3\u003e4. Postoperative additional treatment.\u003c/h3\u003e\n\u003cp\u003eThere are a total of 20 patients with thymoma type B2 and beyond. Additional treatment after surgery for these 20 patients were detailed in the Table\u0026nbsp;4.\u003c/p\u003e\n\u003ch3\u003e5. Postoperative Visual analog pain scores (VSA) and follow-up.\u003c/h3\u003e\n\u003cp\u003ePostoperative pain scores at 24 hours, 48 hours and 3 days after the discharge were assessed. The VAS scores in the group were (6.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89) on the post-operative day (POD) 1, (5.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75) on the POD 2, and (2.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51) 3 days after the discharge. The postoperative VAS scores of the patients were summarized in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAccording to the National Comprehensive Cancer Network (NCCN) guidelines, thoracoscopic thymectomy could be applied to treat Masaoka-Koga stages 1 and 2 thymoma for patients without myasthenia gravis(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)(Table\u0026nbsp;5). Thymectomy is considered as the cornerstone treatment for thymoma. Owing to its superior oncological results, transsternal thymectomy is considered to be the gold standard(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). During recent years, minimal invasive techniques have been accepted as an alternative approach for its advantages and equivalent efficacy. This surgical method could not only ensure complete tumor resection, but also have the preponderance of avoiding the median sternotomy.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) Various approaches have been developed, including unilateral, bilateral, subxiphoid single-port, and intercostal approaches(\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe complete surgical resection in non-myasthenia gravis (MG) patients is the key ingredient for thymomas(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Proponents of complete thymectomy insist on extensive thymectomy including the thymus and the anterior mediastinal adipose tissues resecting (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). However, the necessity of removing the whole thymus gland has been questioned for thymomas without MG (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Recurrence rates were not significantly higher after thymomectomy alone in thymomas patients (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Our recommendation is to perform a complete thymectomy. There are two most important principles in the surgical treatment. One of these is the necessity of removal the whole thymus gland. The other rule is the need of performance of thymectomy with removal of the adipose tissue in the anterior mediastinum.\u003c/p\u003e \u003cp\u003eIn 1999, Akamine et al. reported a case by VATS subxiphoid approach(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This approach allows surgeons to visualize both phrenic nerves and reach high into the anterior mediastinum. It could provide a unique advantage of simultaneous bilateral access to the pleural cavities. In addition, with the support of using CO2 and retractors, the surgical field and exposure the upper mediastinum could be superiorly acquired (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The cephalic-brachial vein and its connection with the superior vena could be more clearly exposure under surgical field of view.\u003c/p\u003e \u003cp\u003eFor the thymoma patients, we followed the principles published by the International Thymic Malignancy Interest Group: resection of thymoma and tissue; dissection and visualization surrounding the innominate vein; removal of the specimen in a specimen bag; and completeness examination(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Multiportal or uniportal subxiphoid thymectomy approaches were reported (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). However, large thymic tumors should be limited due to the inadequate surgical manipulability and limited space. We suggest that the procedure could be performed with an auxiliary sternal retractor in patients (diameter\u0026thinsp;\u0026ge;\u0026thinsp;5cm). A vertical port below the lower edge of the xiphoid was made as the operating pole for ultrasound knife. The two additional small subcostal incisions could avoid interference among the surgical instruments and make the surgical procedure unhindered. In our group, the xiphoid port was made as the main operating hole. The right subcostal incision was made as the accessory operating hole, with the left subcostal incisions as the observational hole. There were several advantages for this approach: 1) During surgery, the patient could be in a supine position to avoid special requirements. 2) The surgical doctors would have good operating space, avoiding instrument interference. 3) Our approach could provide a unique advantage of simultaneous bilateral access to the pleural cavities for ultrasound knife.\u003c/p\u003e \u003cp\u003ePostoperative pain scores at 24 hours, 48 hours and 3 days after the discharge were assessed. The VAS scores in the group were low on the POD 1 (6.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89), POD 2 (5.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75), and 3 days after the discharge (2.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51). This xiphoid process method has significant advantages in reducing postoperative pain by the incision avoidance of the chest ribs.\u003c/p\u003e \u003cp\u003eThere were several advantages for this subxiphoid and subcostal arch approach. Firstly, the anterior mediastinum could be well exposed and three ports facilitated the operation. Secondly, the intercostals nerves compression or injury could be avoided. Thirdly, no separate ventilation was needed. Fourthly, the ultrasound knife in the main operating hole could have a larger operating space for both sides of the chest cavity.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWith the subxiphoid incision as the operating port and an auxiliary sternal retractor, the subxiphoid VATS thymectomy could provide satisfactory therapeutic effect. Subxiphoid video-assisted thoracic surgery has potential advantages of a less postoperative VAS score. Owing to a limited number of cases, further prospective studies are needed to comfirm this favorable effect.\u003c/p\u003e"},{"header":"Limitation","content":"\u003cp\u003eThe present study has several limitations: 1) a retrospective study, 2) a single-group experience in single-center, 3) a small number of cases inclued. 4) without a long-term follow-up period. 5) absence of the comparative analysis group, leading to the incomplete persuasiveness of the research results.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003evideo-assisted thoracic surgery (VATS)\u003c/p\u003e\n\u003cp\u003eWorld Health Organization (WHO)\u003c/p\u003e\n\u003cp\u003eintercostal video-assisted thoracic surgery (IVATS)\u003c/p\u003e\n\u003cp\u003esubxiphoid video-assisted thoracic surgery (SVATS)\u003c/p\u003e\n\u003cp\u003esubxiphoid-approach thoracoscopic thymectomy (SATT)\u003c/p\u003e\n\u003cp\u003eVisual analog pain scores (VSA)\u003c/p\u003e\n\u003cp\u003epost-operative day (POD)\u003c/p\u003e\n\u003cp\u003eNational Comprehensive Cancer Network (NCCN)\u003c/p\u003e\n\u003cp\u003emyasthenia gravis (MG)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enot applicable\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge all members of Department of Thoracic Surgery, 2\u003csup\u003end\u003c/sup\u003e Affiliated Hospital, Zhejiang University, Hangzhou, China for their support. We thank all the group members for their helpful discussions for our paper.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZPY participated in all aspects of the experiment and drafted the article. All authors read and approved the final manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll informed consents were obtained from all participants or from guardians.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This is a retrospective study.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the Ethics Committee of the Second Affiliated Hospital of Zhejiang University. The research involved no more than minimal risk to the participants. This study was retrospective data analysis of previously collected medical records (2024-0463).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll research procedures were conducted in accordance with the ethical standards of the the Ethics Committee of the Second Affiliated Hospital of Zhejiang University, ensuring compliance throughout the study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKondo K. Therapy for thymic epithelial tumors. Gen Thorac Cardiovasc Surg 2014;62:468-474.\u003c/li\u003e\n\u003cli\u003eLo Iacono G, Gigli F, Gherzi L, Avenoso D, Fiori S, Sedda G, Tarella C, et al. Thymoma and pure red cell aplasia with hypoplasia of megakaryocytopoiesis: A rare and life-treating condition. Transfus Apher Sci 2020;59:102656.\u003c/li\u003e\n\u003cli\u003eKelly RJ, Petrini I, Rajan A, Wang Y, Giaccone G. Thymic malignancies: from clinical management to targeted therapies. J Clin Oncol 2011;29:4820-4827.\u003c/li\u003e\n\u003cli\u003eDavenport E, Malthaner RA. The role of surgery in the management of thymoma: a systematic review. Ann Thorac Surg 2008;86:673-684.\u003c/li\u003e\n\u003cli\u003eFriedant AJ, Handorf EA, Su S, Scott WJ. Minimally Invasive versus Open Thymectomy for Thymic Malignancies: Systematic Review and Meta-Analysis. J Thorac Oncol 2016;11:30-38.\u003c/li\u003e\n\u003cli\u003eDetterbeck FC. Clinical value of the WHO classification system of thymoma. Ann Thorac Surg 2006;81:2328-2334.\u003c/li\u003e\n\u003cli\u003eBatirel HF. Minimally invasive techniques in thymic surgery: a worldwide perspective. J Vis Surg 2018;4:7.\u003c/li\u003e\n\u003cli\u003eYu L, Ma S, Jing Y, Zhang Y, Li F, Krasna MJ. Combined unilateral-thoracoscopic and mediastinoscopic thymectomy. Ann Thorac Surg 2010;90:2068-2070.\u003c/li\u003e\n\u003cli\u003eSuda T, Hachimaru A, Tochii D, Maeda R, Tochii S, Takagi Y. Video-assisted thoracoscopic thymectomy versus subxiphoid single-port thymectomy: initial results\u0026dagger;. Eur J Cardiothorac Surg 2016;49 Suppl 1:i54-58.\u003c/li\u003e\n\u003cli\u003eMcMurry TL, Hu Y, Blackstone EH, Kozower BD. Propensity scores: Methods, considerations, and applications in the Journal of Thoracic and Cardiovascular Surgery. J Thorac Cardiovasc Surg 2015;150:14-19.\u003c/li\u003e\n\u003cli\u003eShiomi K, Kitamura E, Ono M, Kondo Y, Naito M, Mikubo M, Matsui Y, et al. Feasible and promising modified trans-subxiphoid thoracoscopic extended thymectomy for patients with myasthenia gravis. J Thorac Dis 2018;10:1747-1752.\u003c/li\u003e\n\u003cli\u003eOdaka M, Tsukamoto Y, Shibasaki T, Katou D, Mori S, Asano H, Yamashita M, et al. Thoracoscopic thymectomy is a feasible and less invasive alternative for the surgical treatment of large thymomas. Interact Cardiovasc Thorac Surg 2017;25:103-108.\u003c/li\u003e\n\u003cli\u003eLu Q, Zhao J, Wang J, Chen Z, Han Y, Huang L, Li X, et al. Subxiphoid and subcostal arch \u0026quot;Three ports\u0026quot; thoracoscopic extended thymectomy for myasthenia gravis. J Thorac Dis 2018;10:1711-1720.\u003c/li\u003e\n\u003cli\u003eAgasthian T. Can invasive thymomas be resected by video-assisted thoracoscopic surgery? Asian Cardiovasc Thorac Ann 2011;19:225-227.\u003c/li\u003e\n\u003cli\u003eZieliński M, Rybak M, Wilkojc M, Fryzlewicz E, Nabialek T, Pankowski J. Subxiphoid video-assisted thorascopic thymectomy for thymoma. Ann Cardiothorac Surg 2015;4:564-566.\u003c/li\u003e\n\u003cli\u003eZhang G, Li W, Chai Y, Wu M, Zhao B, Fan J, Zhang S, et al. Bilateral video-assisted thoracoscopic thymectomy for Masaoka stage IIIA thymomas. Thorac Cardiovasc Surg 2015;63:206-211.\u003c/li\u003e\n\u003cli\u003eWu L, Lin L, Liu M, Jiang L, Jiang G. Subxiphoid uniportal thoracoscopic extended thymectomy. J Thorac Dis 2015;7:1658-1660.\u003c/li\u003e\n\u003cli\u003eWu CF, Gonzalez-Rivas D, Wen CT, Liu YH, Wu YC, Chao YK, Heish MJ, et al. Single-port video-assisted thoracoscopic mediastinal tumour resection. Interact Cardiovasc Thorac Surg 2015;21:644-649.\u003c/li\u003e\n\u003cli\u003eToker A, Sonett J, Zielinski M, Rea F, Tomulescu V, Detterbeck FC. Standard terms, definitions, and policies for minimally invasive resection of thymoma. J Thorac Oncol 2011;6:S1739-1742.\u003c/li\u003e\n\u003cli\u003eZieliński M, Kuzdzał J, Szlubowski A, Soja J. Transcervical-subxiphoid-videothoracoscopic \u0026quot;maximal\u0026quot; thymectomy--operative technique and early results. Ann Thorac Surg 2004;78:404-409; discussion 409-410.\u003c/li\u003e\n\u003cli\u003eOdaka M, Akiba T, Yabe M, Hiramatsu M, Matsudaira H, Hirano J, Morikawa T. Unilateral thoracoscopic subtotal thymectomy for the treatment of stage I and II thymoma. Eur J Cardiothorac Surg 2010;37:824-826.\u003c/li\u003e\n\u003cli\u003eNg CS, Wan IY, Yim AP. Video-assisted thoracic surgery thymectomy: the better approach. Ann Thorac Surg 2010;89:S2135-2141.\u003c/li\u003e\n\u003cli\u003eNakagawa K, Yokoi K, Nakajima J, Tanaka F, Maniwa Y, Suzuki M, Nagayasu T, et al. Is Thymomectomy Alone Appropriate for Stage I (T1N0M0) Thymoma? Results of a Propensity-Score Analysis. Ann Thorac Surg 2016;101:520-526.\u003c/li\u003e\n\u003cli\u003eGu Z, Fu J, Shen Y, Wei Y, Tan L, Zhang P, Han Y, et al. [Thymectomy versus Tumor Resection for Early-stage Thymic Malignancies: A Chinese Alliance for Research in Thymomas (ChART) Retrospective Database Analysis]. Zhongguo Fei Ai Za Zhi 2016;19:459-464.\u003c/li\u003e\n\u003cli\u003eAkamine S, Takahashi T, Oka T, Kishimoto K, Ayabe H. Thymic cystectomy through subxyphoid by video-assisted thoracic surgery. Ann Thorac Surg 1999;68:2339-2341.\u003c/li\u003e\n\u003cli\u003eYano M, Moriyama S, Haneda H, Okuda K, Kawano O, Oda R, Suzuki A, et al. The Subxiphoid Approach Leads to Less Invasive Thoracoscopic Thymectomy Than the Lateral Approach. World J Surg 2017;41:763-770.\u003c/li\u003e\n\u003cli\u003eTakeo S, Sakada T, Yano T. Video-assisted extended thymectomy in patients with thymoma by lifting the sternum. Ann Thorac Surg 2001;71:1721-1723.\u003c/li\u003e\n\u003cli\u003eSuda T. Single-port thymectomy using a subxiphoid approach-surgical technique. Ann Cardiothorac Surg 2016;5:56-58.\u003c/li\u003e\n\u003cli\u003eZhang L, Li M, Jiang F, Zhang Z, Zhang Q, Xu L. Subxiphoid versus lateral intercostal approaches thoracoscopic thymectomy for non-myasthenic early-stage thymoma: A propensity score -matched analysis. Int J Surg 2019;67:13-17.\u003c/li\u003e\n\u003cli\u003eZhong Y, Zhou Y, Jiang L, Lin H, Li X, Wen Z, Long X, et al. Modified Transsubxiphoid Thoracoscopic Extended Thymectomy in Patients with Myasthenia Gravis. Thorac Cardiovasc Surg 2017;65:250-254. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e The baseline clinical data of the patients (N=41)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eIndicator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eResult\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e21(51.22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e20(48.78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e54.90\u0026plusmn;11.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e23.40\u0026plusmn;2.87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eASA grading\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e18(43.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e14(34.15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e9(21.95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e The perioperative indicators data of the patients (N=41)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eIndicator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eResult\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eOperative time(min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e110.88\u0026plusmn;33.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eBlood loss(ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e24.27\u0026plusmn;33.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eLength of stay(days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e3.59\u0026plusmn;2.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eDrainage volume(ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e7.51\u0026plusmn;7.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eExtubation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e41(100%)\u003c/p\u003e\n \u003cp\u003e0(0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eConversion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e1(2.44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e40(97.56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003eThe morbidity and mortality data of the patients were summarized (N=41)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eIndicator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eResult\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eType\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e4(9.76%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eAB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e12(29.27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eB1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e3(7.32%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eB1/B2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e2(4.88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eB2/B3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e3(7.32%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eB2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e8(19.51%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e2(4.88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e7(17.07%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eSize(mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e46.01\u0026plusmn;22.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eComplication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e41(100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 4.\u0026nbsp;Additional treatment after surgery (N=20)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"792\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.9621%;\"\u003e\n \u003cp\u003eType\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6877%;\"\u003e\n \u003cp\u003eB2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6308%;\"\u003e\n \u003cp\u003eB2/ B3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6308%;\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6308%;\"\u003e\n \u003cp\u003eC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.4576%;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.9621%;\"\u003e\n \u003cp\u003eThymoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6877%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6308%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6308%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6308%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.4576%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.9621%;\"\u003e\n \u003cp\u003eAdditional treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6877%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6308%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6308%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6308%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.4576%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.9621%;\"\u003e\n \u003cp\u003eDeclining Additional treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6877%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6308%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6308%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6308%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.4576%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 5. Masaoka\u0026ndash;Koga staging system.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"737\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8453%;\"\u003e\n \u003cp\u003eInstallments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78.1547%;\"\u003e\n \u003cp\u003ePerformance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8453%;\"\u003e\n \u003cp\u003ePhase I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78.1547%;\"\u003e\n \u003cp\u003eThe envelope was complete and no tumor cells invaded the envelope\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8453%;\"\u003e\n \u003cp\u003ePhase II a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78.1547%;\"\u003e\n \u003cp\u003eMicroscopically, the tumor cells invaded the envelope\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8453%;\"\u003e\n \u003cp\u003ePhase II b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78.1547%;\"\u003e\n \u003cp\u003eTumor cells infiltrated into the pleural or adipose tissue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8453%;\"\u003e\n \u003cp\u003ePhase III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78.1547%;\"\u003e\n \u003cp\u003eTumor cells invaded adjacent organs such as the lungs,\u003c/p\u003e\n \u003cp\u003epericardium, large blood vessels, and more\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8453%;\"\u003e\n \u003cp\u003ePhase IVa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78.1547%;\"\u003e\n \u003cp\u003eThe tumor occurred with implant metastases to the pleural or\u003c/p\u003e\n \u003cp\u003epericardium\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8453%;\"\u003e\n \u003cp\u003ePhase IVb\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78.1547%;\"\u003e\n \u003cp\u003eTumor cell metastases through the lymphatic tract or blood,\u003c/p\u003e\n \u003cp\u003ewith distant metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Thymectomy, Thymoma, Subxiphoid approach, Video-assisted thoracic surgery, Sternal retractor","lastPublishedDoi":"10.21203/rs.3.rs-7943944/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7943944/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eMinimally invasive approaches are widespreadly being applied via different routes for thymoma. The present study aimed to assess the perioperative outcomes of the subxiphoid approach in video-assisted thoracic surgery (VATS) thymectomy for non-myasthenia thymoma patients in our group.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients who underwent VATS thymectomy via subxiphoid approach between 2020 and 2023 were retrospectively analyzed in our medical group. 41 patients were finally included for peri-operative outcomes analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThere was 1 conversion to median sternotomy owing to inominate vein injury and hemorrhage (\u0026ge;\u0026thinsp;300ml). All patients achieved a good recovery after surgery, and none had serious complications. There were no perioperative deaths. 10 patients underwent post-operative adjuvant radiotherapy. 10 patients refused to receive post-operative adjuvant radiotherapy.\u003c/p\u003e\u003ch2\u003eCONCLUSION\u003c/h2\u003e \u003cp\u003eWith the subxiphoid incision as the operating port, the subxiphoid VATS thymectomy could provide satisfactory therapeutic effect when an auxiliary sternal retractor is needed (diameter of thymoma\u0026thinsp;\u0026ge;\u0026thinsp;5cm). This method has significant advantage in reducing postoperative acute phase pain.\u003c/p\u003e","manuscriptTitle":"A retrospective for perioperative outcomes of the subxiphoid video-assisted thoracic surgery thymectomy in non-myasthenia thymoma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 08:59:33","doi":"10.21203/rs.3.rs-7943944/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bd57b65b-dbff-4070-86fb-986291cfd459","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-11T08:42:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-22 08:59:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7943944","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7943944","identity":"rs-7943944","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}