Comparative effectiveness of video-assisted thoracoscopic surgery versus open thymectomy for thymoma: a propensity score-matched analysis of 317 patients

BACKGROUND: Although video-assisted thoracic surgery (VATS) thymectomy has been widely adopted for thymoma resection, its comparative effectiveness versus open approaches (thoracotomy and sternotomy) remains controversial. This study aimed to comprehensively evaluate perioperative and long-term outcomes among these surgical modalities. METHODS: In this retrospective cohort study, 317 consecutive patients with pathologically confirmed thymoma underwent surgical resection at Beijing Chest Hospital (2005-2024). Patients were stratified by approach: VATS (n = 178), unilateral thoracotomy (n = 73), and median sternotomy (n = 66). Propensity score weighting (PSW) was applied to balance baseline covariates. Primary endpoints included intraoperative metrics (blood loss, operative time), postoperative recovery (chest tube duration, hospital stay), and oncologic outcomes (recurrence-free survival [RFS], overall survival [OS]). RESULTS: Intraoperative Outcomes: Sternotomy demonstrated significantly longer operative time (median 138.0 [IQR 120-180] vs. 100.0 [75.4-150.7] vs. 120.0 [90-150] minutes; P = 0.008) and greater blood loss (median 291.5 [200-403] vs. 100.0 [50-200] vs. 50.0 [50-100] mL; P < 0.001) compared to thoracotomy and VATS, respectively. Postoperative Outcomes: Sternotomy required higher postoperative pleural drainage volume (median 848.4 [620-1524.7] vs. 632.9 [450-1020] vs. 540.0 [340-742.2] ml; P = 0.002) and extended hospitalization (median 14.0 [11-19.5] vs. 9.16 [8-14] vs. 9.0 [7-13] days; P < 0.001). Survival Analysis: Multivariable Cox models revealed no statistically significant differences were observed in OS (thoracotomy vs. VATS: HR = 2.44, 95% CI 0.70-8.42, P = 0.158; sternotomy vs. VATS: HR = 1.89, 95% CI 0.45-7.48, P = 0.361) or RFS (thoracotomy HR = 0.56, 95% CI 0.16-1.94; sternotomy HR = 0.74, 95% CI 0.16-3.37) across approaches (all P > 0.05). Advanced Masaoka-Koga stage (III/IV) independently predicted worse OS (HR = 2.88, 95% CI 1.13-7.33, P = 0.027). CONCLUSION: Preliminary evidence showed that VATS provided short-term superior perioperative outcomes with significantly less blood loss and shorter hospital stays compared to sternotomy, while maintaining comparable long-term survival across surgical approaches. Given the retrospective nature and methodological limitations of this study, these observations require rigorous confirmation through prospective multicenter studies to establish evidence-based guidelines for surgical approach selection.