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Ann Thorac Surg 2001;72:667-668
© 2001 The Society of Thoracic Surgeons
a Division of Neurosurgery, National Taiwan University Hospital, No. 7 Chung-Shan S. Rd, Taipei, Taiwan
To the Editor
I read with interest the article by Lee and associates [1] and congratulate them on their successful results.
In 1990, we first developed "video" endoscopic transthoracic sympathectomy to treat palmar hyperhidrosis (PH) [2]. Subsequently, the procedure was soon shown to be easy, safe, and effective and became widely accepted as a standard treatment for PH [3, 4]. Based on our extensive experience in the treatment of PH, we would like to further comment on several important points.
The incidence of axillary hyperhidrosis (AH) is unusually low in the present report (4 in 94 patients). Based on our experience, PH is associated with AH in more than 50% of patients, with an even higher incidence after puberty [4].
Most PH patients treated by upper thoracic sympathectomy also experienced concomitant reduction in their facial sudomotor activity without complication of ptosis. Therefore, in 1991, we first introduced the procedure of transthoracic endoscopic ablation of sympathetic T2 segment to treat facial hyperhidrosis (FH) [5] and have achieved very satisfactory results. Based on our abundant experience, we have proven that ablation of the T2 segment is simple and effective for FH and especially more safe than the resection of first ganglion as proposed by the author concerning the risk of Horner’s syndrome.
The incidence of postsympathectomy compensatory hyperhidrosis (PCH) varies with patient’s geographic location, working environment, humidity, temperature, and the season when it is surveyed, so that the reported incidence varies greatly from 30 to 85% [4].
Furthermore, the severity, rather than the incidence of PCH, is related to the extent of sympathectomy, so that the more extensive the sympathectomy, the more serious the PCH [4]. Because of this, we emphasize the use of a simple physiological monitoring technique (intraoperative monitoring of palmar skin temperature) to confirm an adequate sympathectomy that will lead to definite therapeutic results. Consequently, we have demonstrated that en bloc ablation of the T2 sympathetic segment overlying the second rib bony head should be considered as an adequate extent of sympathectomy for PH [3, 6].
It is interesting that the severity of PCH is particularly serious in those PH patients with inherent high systemic sudomotor activity, who have hyperhidrosis not only on the palms, axilla, and soles, but also on the head, face, and trunk, as a genetic factor plays an important role. In contrast, it is of particular interest to find that patients with cerebroischemic syndrome who received thoracic sympathectomy rarely developed substantial PCH. The etiology of PCH is still unclear. Obviously, it is not simply a compensatory hyperhidrosis transposition from postoperative reduction of palmar sweating. Based on our observations, we postulated two possible mechanisms. The first of these mechanisms is denervation hypersensitivity of the surgically injured distal sympathetic stump. This could explain why CH may appear soon after sympathectomy, but is not found in patients who undergo local excision of axillary sweat glands or undergo local treatment. Another mechanism is regeneration of preganglionic fibers or collateral sprouting of sympathetic fibers from the proximal stump of the sympathetic trunk. This could explain the long-term existence of PCH.
Using an 8-mm operating thoracoscope, with the patient in a back-elevated supine position and with temporary disconnection of the ventilator from the patient, the upper lung will spontaneously collapse from the upper thorax once the trocar is inserted due to a relative negative pressure in the intrathoracic cavity. Therefore, the procedure of instillation of CO2 gas can be avoided.
Based on our experience, a conventional 8-mm operating thoracosope with one entry port is a simpler and more convenient technique for sympathectomy than the use of two ports with a 2-mm needle scope and endoscissors. With both techniques, the postoperative wound pain and scarring are almost the same and both are negligible.
We believe that the above-mentioned points may be useful for those practicing endoscopic sympathectomy.
References
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  P. B. Licht, O. D. Jorgensen, L. Ladegaard, and H. K. Pilegaard Thoracoscopic Sympathectomy for Axillary Hyperhidrosis: The Influence of T4 Ann. Thorac. Surg., August 1, 2005; 80(2): 455 - 460. [Abstract] [Full Text] [PDF]
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