Is a subxiphoid approach equivalent to midline sternotomy for extended thymectomy for achieving disease remission in patients with myasthenia gravis?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients with myasthenia gravis undergoing extended thymectomy, is a subxiphoid approach equivalent to midline sternotomy for achieving disease remission?' Altogether 106 papers were found using the reported search, of which 5 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Five studies of a total of 803 patients with myasthenia gravis (MG) reported their experience with thymectomy by subxiphoid approach versus thymectomy by midline sternotomy. These studies demonstrated shorter operation duration, reduced intraoperative blood loss, reduced hospital length of stay and lower postoperative pain scores in the subxiphoid group. There was no significant difference in rates of postoperative MG crisis between the 2 groups, and similar rates of improvement in quantitative myasthenia gravis scores. We conclude that while further high-quality research is required, thymectomy by subxiphoid approach for MG may be considered in preference to midline sternotomy due to improved short-term postoperative outcomes and similar disease remission rates.