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Ann Thorac Surg 1997;64:975-978
© 1997 The Society of Thoracic Surgeons

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Original Article: General Thoracic

Thoracoscopic Sympathectomy for Upper Limb Hyperhidrosis: Looking for the Right Operation

Department of Surgery, Saint-Louis Hospital, Paris, France

Accepted for publication April 8, 1997.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. Thoracoscopic sympathectomy is the most effective treatment for upper limb hyperhidrosis. However, this is offset by the occurrence of a high rate of side effects, such as embarrassing compensatory sweating. Anticipating that a technique that respects the sympathetic chain and divides only the rami communicantes may lead to fewer side effects, we assessed the technique described by R. Wittmoser, comparing it with conventional thoracoscopic sympathecomy.

Methods. A total of 240 thoracoscopic sympathectomies were performed in 124 patients suffering from upper limb hyperhidrosis. Fifty-four patients underwent a conventional sympathectomy (group TS), 62 underwent division of the rami communicantes with respect to the main trunk (group SS), and 8 underwent both procedures (group TS/SS) because of accidental division of the chain during dissection. The mean follow-up is 8 months.

Results. No recurrence was observed in group TS whereas six (5%) occurred in group SS (p < 0.05). The global rate of compensatory sweating was about the same in both groups: 72.2% in group TS and 70.9% in group SS. However, the rate of embarrassing or disabling compensatory sweating was significantly higher in group TS (50%) than in group SS (21%) (p < 0.001).

Conclusions. Although selective division of the rami communicantes results in a significant decrease in the rate of disturbing side effects, it also leads to recurrences that are usually not observed at that level in patients treated with the conventional technique. Therefore other means of achieving the ideal operation should be explored, that is, a technique associated with a high success rate but a minimal number of side effects.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Thoracic sympathectomy has been known for years to be the most effective treatment for upper limb hyperhidrosis (HH) when medical therapy and iontophoresis have failed [1]. Findings from numerous large series have been published, and reported success rates for the procedure have ranged from 94% to 98% [2–5]. More recently, with the development of minimally invasive surgery and video-assisted thoracic surgery, endoscopic thoracic sympathectomy has become the treatment of choice [3]. However, despite the general consensus about the effectiveness of sympathectomy in alleviating this disabling and distressing condition, some authors have suggested that the long-term results may not be as satisfactory as usually asserted [4]. There is some degree of dissatisfaction, related not so much to recurrences but to the development of disturbing side effects, especially compensatory sweating (CS). We have also observed this side effect in our initial experience, and it led us to look into the technique described by R. Wittmoser [6]. This technique consists in dividing only the rami communicantes while respecting the sympathetic trunk. We have performed this procedure in 62 consecutive patients and compared the results in them to those in our initial series of 54 patients who were operated on in a conventional manner. Although these two groups have not been randomized, they are comparable and all patients have been studied prospectively.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
From October 1, 1993, to November 1, 1996, we operated on 174 patients with HH. To have a minimum follow-up of 8 months, only the first 124 patients were studied. Because most of the procedures have been bilateral, a total of 240 sympathectomies were performed in these 124 patients. Sixty-four patients (51.6%) complained of palmar HH alone and 53 (42.7%) of palmar and axillary HH. Only 7 (5.6%) suffered mainly from isolated axillary HH. A conventional technique was used at the beginning of our experience. It consists in the division of the whole sympathetic trunk from the second (T2) to the fourth thoracic ganglion (T4), or down to T5 when the axilla is involved. By analogy to vagotomies, we named this technique truncal sympathectomy (TS). After having used this procedure in 54 patients, we became concerned about the high rate of embarrassing CS and switched to using a technique described by R. Wittmoser, in which only the rami communicantes from T2 to T4 or T5 are divided. We called this technique selective sympathectomy (SS).

The whole series consisted of 42 male and 82 female patients ranging in age from 15 to 52 years (average, 28.1 years). There were 54 patients in group TS and 62 patients in group SS. Both groups were comparable in terms of age and the sex distribution. A third, minor, group (TS/SS) consisted of 8 patients who underwent an SS on one side and a TS on the opposite side. This occurred because, although a bilateral SS was planned, the sympathetic chain on one side was accidentally divided during dissection.

The procedure was performed with the patient under general anesthesia using one-lung ventilation. The patient was placed in the thoracotomy position with the upper limb abducted and raised. Three entry sites were used. One 5-mm port in the axilla was used for a 5-mm, 0-degree telescope (Olympus Winter & Ibe, Hamburg, Germany), and two other 3-mm ports were used for the introduction of microinstruments that we have developed for this purpose (Pilling-Weck-Europe, Le Faget, France). Two of the trocars were inserted in the axilla in the third intercostal space, and the third one was inserted in the back, 2 cm below the scapula. To dissect the sympathetic chain, the parietal pleura was opened along the main trunk using diathermy. The sympathetic chain was dissected with scissors without diathermy to prevent any diathermic injury to the stellate ganglion. The chain in group TS was divided and removed en bloc from the lower part of the stellate ganglion (T1) to T4 or T5. A similar dissection was carried out in group SS, but only the rami communicantes were divided. The main trunk was respected and lifted up so that we could look for any residual branch. The procedure was completed with electrocoagulation of the body of the second, third, and fourth ribs for a distance of 3 to 4 cm, as recommended by Linder and associates [7]. The purpose of this is to divide any small accessory branches of the sympathetic chain (nerve of Kuntz), which are present in about 10% of patients and that may be overlooked [6].

In both groups, a small (16F) chest tube was kept in place for a few hours and removed after the chest x-ray study showed no untoward findings. All patients were discharged the day after the operation and then readmitted 2 or 3 weeks later for the contralateral operation.

All patients were seen 3 months after operation and then contacted by phone. They were questioned about side effects and the occurrence of CS. Compensatory hyperhidrosis was graded as follows: 1, absent; 2, minor and intermittent; 3, embarrassing (ie, visible sweating); and 4, disabling (ie, need to get changed during the day). All data were collected in a data base (File-Maker Pro, Claris) and filed at the time of operation and during follow-up.

To compare the recurrence rate, statistical analysis was performed using the ² test with a Yates correction. To compare the rate of occurrence of CS, statistical analysis was performed using the ² test.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
There were no deaths. One left chylothorax occurred and healed spontaneously. We have reported this rare complication in a case report [8]. Four other minor postoperative complications were observed (4.3%): three pneumothoraces, one of which required 24 hours of chest drainage, and one pleural effusion, which disappeared after physiotherapy. No Horner's syndrome was noticed. Most patients were discharged the day after operation. The mean duration of stay in patients undergoing either procedure was 2.3 days (range 1 to 12 days). In all but 1 patient, the hands or axillae, or both, became dry immediately after the procedure. In 1 patient in group SS, the procedure was unsuccessful and prompted an immediate reoperation.

At a mean follow-up of 11 months, there were no recurrences in group TS and six recurrences (5%) in group SS. The difference was statistically significant (p < 0.05). All relapses have followed the same pattern; that is, first there was a return of sweating on the ulnar aspect of the hand that then progressively extended to the whole hand between the fourth to seventh postoperative month. One patient experienced a bilateral recurrence. All but 1 patient suffering from recurrence were reoperated on, and these underwent complete division of the sympathetic chain. In group TS/SS, 1 patient's HH recurred in the upper limb on the side treated by an SS, whereas the opposite hand remained dry.

The CS is broken down by grade in Table 1. The global rate of CS was about the same in both groups: 72.2% in group TS and 70.9% in group SS. Two patients in group TS reported a disabling CS, and this was also noticed by the surgeon at consultation (Fig 1). No distressing CS has been noticed in group SS. Finally, there was significantly less disabling and embarrassing CS (p < 0.001) in the patients in group SS (Fig 2).

View larger version (144K): [in this window] [in a new window]   Fig 1. . Severe compensatory hyperhidrosis of the trunk 3 years after truncal sympathectomy for palmar hyperhidrosis. Note the change in the skin pigmentation in the area of compensatory sweating.

View larger version (59K): [in this window] [in a new window]   Fig 2. . Comparison of compensatory sweating rates after truncal sympathectomy (TS) and selective sympathectomy (SS) (P < 0.001 for between-group comparison). (shaded bars = absent or moderate; white bars = embarrassing or disabling.)

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

Despite the fact that follow-up has been limited in most of our patients because we have only recently begun to use these procedures, this series already gives some indications. The absence of recurrence in group TS matches the results of many similar series, for which recurrence rates ranging from 1.5% to 6.5% have been reported [2–5, 9]. According to most authors, recurrences generally appear within the first 15 months [5, 9]. Herbst and associates [4] have followed up 323 patients for an average of 14 years and have found only a 1.5% recurrence ratio. Thus the 10% recurrence rate (6 patients) in our patients in group SS at an average follow-up of 8 months is much higher than that reported for conventional sympathectomy. One of the reasons for this might be our missing accessory branches and the nerve of Kuntz [6, 10]. However, we have always looked thoroughly for these branches, whatever the technique used. We have also coagulated the body of the corresponding ribs for a distance of 3 cm in order to divide any dorsal root that, might run intradurally, a technique recommended by Linder and associates [7] as well as Lemmens [11]. Lemmens [11] has reported performing reoperations in 19 patients suffering recurrence after conventional sympathectomy. Seventeen were cured using costotransversotomy, that is, electrocoagulation of the rib body, at the level of second and third ribs. Because we have used exactly the same dissection, the same division of rami communicantes, and the same coagulation of the rib body in groups TS and SS, we have to acknowledge that respecting the sympathetic chain may have led to regeneration of the sympathetic ganglia [10]. This would explain the early relapses in group SS. Leflaucheur and colleagues [12] have suggested that the axonal growth of sympathetic fibers is the most likely explanation for recurrences.

Side effects and CS are described in most articles dealing with HH. However, CS is usually mentioned as a minor nuisance, something like the price to pay for relief of the disease. Compensatory sweating occurs in 50% to 67% of patients (Table 2). Few authors have distinguished between usual CS and disabling CS (Table 2). Those who did have stated that only a small percentage of the patients considered the CS to be worse than their initial disease [2, 3, 13]. According to Herbst and associates [4], CS is the main cause of patient dissatisfaction. In their series, the initial satisfaction rate was high (98%), as it is in most series. However, the satisfaction rate declined with time down to 66%, mainly because of embarrassing side effects. Patients with excessive axillary sweating were the least satisfied (33%).

By using a limited sympathectomy that respects the sympathetic chain and by dividing only the rami communicantes, we have reduced the rate of severe CS; however, the global rate of CS remains high. In addition, this slight improvement has been obtained at the cost of a high rate of recurrence. Thus SS does not seem to be the answer to the problem of CS. Other ways that may be explored include limited TS [13, 15] or even unilateral TS [13] (Table 3). It is known that unilateral sympathectomy can be beneficial in managing HH in the contralateral limb, with less risk of CS [13]. This has also been our experience in patients operated on in two stages; they usually do not experience any side effect after the first operation but complain of sweating immediately after the second procedure. Unilateral sympathectomy might be an alternative for those who live in hot climates, that is, those who are likely to have major CS. Sympathectomy should be thoroughly considered for patients with isolated axillary HH [4]. Regardless, patients should be made clearly aware of the fact that none of the currently available techniques is perfect and that they may experience troublesome side effects.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr Gossot, Department of Surgery, Saint-Louis Hospital, 1 Avenue Cl Vellefaux, F-75010 Paris, France (e-mail: d.gossot{at}chu-stlouis.fr).

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

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9. Hashmonai M, Kopelman D, Kein O, Schein M. Upper thoracic sympathectomy for primary palmar hyperhidrosis: long-term follow-up. Br J Surg 1992;79:268–71.[Medline]
10. Van Rhede EJH, Jörning PJG. Resympathectomy of the upper extremity. Br J Surg 1990;77:1043–5.[Medline]
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12. Leflaucheur JP, Fitoussi M, Becquemin JP. Abolition of sympathetic skin responses following endoscopic thoracic sympathectomy. Muscle Nerve 1996;19:586–96.
13. Rennie JA. Compensatory sweating: an avoidable complication of thoracoscopic sympathectomy? [Abstract]. Minimally Invas Ther Allied Technol 1996;5:101.
14. Shelley WB, Florence R. Compensatory hyperhidrosis after sympathectomy. N Engl J Med 1960;263:1056–8.
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Dominique Gossot Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gossot, D. Articles by Célérier, M. Search for Related Content PubMed PubMed Citation Articles by Gossot, D. Articles by Célérier, M.