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Ann Thorac Surg 2004;78:1052-1055
© 2004 The Society of Thoracic Surgeons

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Original article: general thoracic

Selective division of T3 rami communicantes (T3 ramicotomy) in the treatment of palmar hyperhidrosis

^a Respiratory Center, Department of Thoracic and Cardiovascular Surgery, Yongdong Severance Hospital, Yonsei University College of Medicine, Seoul, People's Republic of China
^b Department of Thoracic and Cardiovascular Surgery, Eulji University Hospital, Deajeon, Korea, People's Republic of China

Accepted for publication March 8, 2004.

^* Address reprint requests to Dr Lee, Department of Thoracic and Cardiovascular Surgery, Respiratory Center, Yongdong Severance Hospital, Yonsei University College of Medicine, 146-92, Dogok-dong, Kangnam-gu, Seoul, South Korea, People's Republic of China 135-720
dylee{at}yumc.yonsei.ac.kr

Presented at the Poster Session of the Fortieth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 26–28, 2004.

	Abstract

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BACKGROUND: Compensatory sweating (CS) is the main cause of a patient's dissatisfaction after sympathetic surgery for palmar hyperhidrosis. Preservation of the sympathetic nerve trunk and limitations on the range of dissection are necessary to reduce CS.

METHODS: We compared 64 patients (31 male, 33 female) (group 1) who underwent a T2 sympathicotomy between July 1998 and February 1999 and 83 patients (58 male, 25 female) (group 2) who underwent a T3 ramicotomy between August 2000 and December 2002.

RESULTS: In group 1, 60 patients (93.8%) exhibited a decreased sweating on both hands, but 4 patients (6.2%) exhibited a persistent sweating on both hands. For group 2, 58 patients (69.9%) experienced a decreased sweating on both hands, 15 patients (18.1%) experienced a persistent sweating on both hands, and 10 patients (12.0%) experienced a persistent sweating on one hand. The grade of CS in group 2 was significantly lower than in group 1 (p < 0.001) and, notably, the rate of embarrassing and disabling CS in group 2 (15.5% [9 out of 58]) was significantly lower than in group 1 (43.3% [26 out of 60], p value < 0.001). The rate of satisfaction was 78.1% (50 out of 64) for group 1 and 68.6% (57 out of 83) for group 2 with no significant statistical difference indicated (p = 0.202).

CONCLUSIONS: The incidence of sweating postoperatively was relatively high in the T3 ramicotomy group, although the T3 surgery did result in a lower incidence of CS when compared with a T2 sympathicotomy.

	Introduction

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Compensatory sweating (CS) is a troublesome side effect that typically occurs after sympathetic surgery. The incidence of CS after endoscopic thoracic sympathetic surgery (ETS) has been reported to be as high as 83%–86% [1–3], although some low incidences of CS have been reported (3%) [4]. To decrease CS, ETS for the treatment of palmar hyperhidrosis has changed direction to attempt to limit the extent of resection of the sympathetic nerve. The conventional sympathetic nerve surgery was a T2 sympathectomy or sympathicotomy. This procedure does not greatly decrease the occurrence of CS after sympathetic surgery [5].

We have performed a modified selective resection of the sympathetic T3 rami communicantes (a T3 ramicotomy) since August 2001 and we compared the rate of satisfaction, the dryness of hands, and the CS between the T2 sympathicotomy procedure and the T3 ramicotomy to evaluate the results of the T3 ramicotomy.

	Material and methods

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We compared 64 patients (group 1) who underwent a T2 sympathicotomy for palmar hyperhidrosis between July 1998 and February 1999 and 83 patients (group 2) who underwent T3 ramicotomy between August 2000 and December 2002. All of the patients were followed using a telephone questionnaire. The follow-up duration for groups 1 and 2 were 9.7 ± 1.3 months and 6.6 ± 3.7 months, respectively. The dryness of hands was graded as follows: 1 = excessive dryness, 2 = dry, and 3 = persistent (sweating of the hand did not improve). CS was graded as follows: 1 = absent, 2 = minor and intermittent, 3 = embarrassing (visible sweating), and 4 = disabling (there was a need to change clothes during the day). We also evaluated the rate of satisfaction, the grade of dryness, and the grade of CS after a T2 sympathicotomy and T3 ramicotomy.

We obtained permission from the patients and the ethics committee at our hospital to perform a T3 ramicotomy on the patients with palmar hyperhidrosis because a T3 ramicotomy was a more recent and relatively untried operative procedure.

The data were analyzed with SPSS 11.0 statistical software (SPSS Inc., Chicago, IL) with probability values of less than 0.05 considered as significant. Distributions of continuous variables were expressed as means ± the standard deviation. Categorical variables were analyzed using the ² test and continuous data were analyzed using the Student's t test.

	Operative techniques

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Procedures were performed on the patient who was placed in a Semifowler position under general anesthesia using a single lumen endotracheal tube. One port was created for the insertion of a telescope (Olympus Winter & Ibe, Hamburg, Germany) on the anterior axillary line and the sixth intercostal space. A 2-mm needle thoracoscope was used for the T2 sympathicotomy and a 5-mm thoracoscope was used for the T3 ramicotomy. Between 1500–1700 ml of CO₂ gas was instilled into the thoracic cavity to gradually deflate the lung. Another port was created for the insertion of an endoscopic instrument on the midaxillary line and third intercostal space. To dissect the sympathetic chain, the parietal pleura were opened along the main sympathetic trunk using 5-mm electrical scissors. The sympathetic chain was dissected with endoscope scissors and, if possible, without any diathermic injury. In the T2 sympathicotomy, the chain was ablated with a 2-mm electrical diathermy on the upper border of the second rib (Fig 1A). In the T3 ramicotomy, a similar dissection was carried out, but only the T3 rami communicantes were divided (Fig 1B). The main trunk was lifted upward to observe the presence of any residual branches. The same procedures were performed on the contralateral side. Barring any complications, most of the patients were discharged on the same day or the day after surgery.

View larger version (249K): [in this window] [in a new window]   Fig 1. T2 sympathicotomy was performed on the upper border of the second rib (A) and T3 ramicotomy was performed in the third intercostal space (B).

	Results

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View larger version (56K): [in this window] [in a new window]   Fig 2. The dryness of hand after T2 sympathicotomy and T3 ramicotomy.

View larger version (61K): [in this window] [in a new window]   Fig 3. The grade of compensatory sweating after T2 sympathicotomy and T3 ramicotomy excluding patients with persistent sweating postoperatively.

	Comment

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It is recognized that the extent of surgery is directly associated with postoperative CS. Shelley and colleagues [6] have described CS after sympathectomy. Using Berkow's surface area formation, they illustrated that the magnitude of sweat gland function diminishes by as much as 40% after sympathectomy. Although it is difficult to prove, many scientists have proposed that CS was more severe when more ganglions were removed. Hsu and colleagues [7] reported that by excising the T2 sympathetic ganglion alone, a reduction in CS decreased from 64%–25% in comparison with a T2–T4 sympathectomy.

Gossot and colleagues [8] analyzed a group of T2, T3, T4 sympathectomy patients in comparison with a group of patients undergoing a T2, T3, T4 ramicotomy and they reported no statistical difference regarding the incidence of CS between the two groups studied (72.2% and 70.9%). However in terms of the severity of CS (embarrassing, disabling) causing inconveniences to daily life, they reported 27% and 13% incidences in these two groups, respectively. These findings suggest that by preserving the sympathetic trunk, it was possible to reduce the severity of CS.

The preganglionic fibers of the sympathetic nerve to the arm originate mostly from the spinal segments T3–T6 and the postganglionic fibers of the sympathetic nerve to the arm originate from T2 and, to a lesser extent, the T3 ganglia [9]. This implies that the division of preganglionic fibers (rami communicantes) reduces the extent of denervation of the sympathetic nerve as compared with the division of postganglionic fibers (sympathetic trunk) in the treatment of palmar hyperhidrosis.

Sympathectomy or sympathicotomy is one of the procedures used to divide the sympathetic trunk. Sympathicotomy distinctively changes sympathetic nerve distribution in comparison with a ramicotomy. Figure 4A illustrates the clear-cut changes of skin temperature after a T2 sympathicotomy. However the overall sympathetic nerve distribution to the body is not markedly changed after a T3 ramicotomy because a T3 ramicotomy is a procedure that is used to divide one of the preganglionic fibers and to preserve the sympathetic trunk. Figure 4B illustrates an even distribution of skin temperature after T3 ramicotomy.

View larger version (239K): [in this window] [in a new window]   Fig 4. Digital infrared thermal image after T2 sympathicotomy or T3 ramicotomy. (A) Clear cut change of skin temperature after a T2 sympathicotomy. (B) An even distribution of skin temperature after ramicotomy.

Lin and associates [11] reported that the hypothalamus received afferent thermal information from central and peripheral thermal stimuli and the hypothalamus then released efferent signals to the sweat glands. After T1 or T2 sympathetic surgery, negative feedback signs from the T1, T2 sympathetic ganglion to the hypothalamus were blocked and so the efferent signals from the hypothalamus were amplified. These amplified signals induce excessive sweating on the entire body, especially on the back, abdomen, and thigh, but obviously this is with the exception of the areas of sympathetic nerve denervation. It is theoretically necessary to preserve the T1 or T2 ganglion, which is the main ganglion for negative feedback on thermoregulation. The preservation of the second sympathetic ganglion in the treatment of palmar hyperhidrosis is an important factor with regard to the reduction of CS.

We believe that a T3 ramicotomy limits the denervation of the sympathetic nerve and preserves the sympathetic trunk. This results in a decrease of CS. Because the range of a sympathetic nerve block is limited in ramicotomy, we have determined that the incidence of excessive hand dryness was also decreased. However the incidence of sweating of the hands was higher in T3 ramicotomy when compared with T2 sympathicotomy, which is one of the disadvantages of T3 ramicotomy.

Patients who experienced persistent sweating after ramicotomy and who hoped to treat the hyperhidrosis were able to undergo other methods of sympathetic surgery such as sympathicotomy or sympathectomy, because the sympathetic trunk was still preserved. In this study sympathicotomy had to be performed in 8 of the 25 patients who experienced persistent sweating after T3 ramicotomy; all of these patients experienced decreased sweating of the hands.

The primary reason for the high incidence of persistent sweating after T3 ramicotomy is that the range of sympathetic surgery is limited compared with conventional T2 sympathicotomy. The second reason is that abnormal rami communicantes that originate from the intercostal nerve and connect to other ganglion are present [12].

In conclusion the incidence of postoperative sweating was relatively high in the T3 ramicotomy group, although the T3 surgery did result in a lower incidence of CS when compared with a T2 sympathicotomy. To increase the success rate of the T3 ramicotomy, the additional ramicotomy of T4 level and the division of aberrant rami communicante bundles may help to reduce the sweating of the hands.

	References

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1. Reisfeld R, Nguyen R, Pnini A. Endoscopic thoracic sympathectomy for treatment of essential hyperhidrosis syndrome: experience with 650 patients. Surg Laparosc Endosc Percutan Tech. 2000;10:5–10[Medline]
2. Gossot D, Galetta D, Pascal A, et al. Long-term results of endoscopic thoracic sympathectomy for upper limb hyperhidrosis. Ann Thorac Surg. 2003;75:1075–1079[Abstract/Free Full Text]
3. Lin TS, Kuo SJ, Chou MC. Uniportal endoscopic thoracic sympathectomy for treatment of palmar and axillary hyperhidrosis: analysis of 2000 cases. Neurosurgery. 2002;51:84–87
4. Duarte JB, Kux P. Improvements in video-endoscopic sympathicotomy for the treatment of palmar, axillary, facial and palmar-plantar hyperhidrosis. Eur J Surg 1998;(Suppl 580):9–11
5. Lee DY, Yoon YH, Shin HK, et al. Needle thoracic sympathectomy for essential hyperhidrosis: intermediate-term follow-up. Ann Thorac Surg. 2000;691:251–253
6. Shelley WB, Florence R. Compensatory hyperhidrosis of sympathectomy. N Engl J Med. 1960;263:1056–1058
7. Hsu CP, Chen CY, Lin CT, et al. Video-assisted thoracoscopic T2 sympathectomy for hyperhidrosis palmaris. J Am Coll Surg. 1994;181:540–542
8. Gossot D, Toledo L, Fritsch S, et al. Thoracoscopic sympathectomy for upper limb hyperhidrosis: looking for the right operation. Ann Thorac Surg. 1997;64:975–978[Abstract/Free Full Text]
9. Gray H. The sympathetic nerves. Lewis WH. Anatomy of the Human Body. 20th edition. Philadelphia: Lea & Febiger; 2000. p. 1292–1299
10. Kao MC, Chen YL, Lee YS, et al. Craniofacial hyperhidrosis treated with video endoscopic sympathectomy. J Clin Laser Med Surg. 1994;12:93–95[Medline]
11. Lin CC, Telaranta T. Lin-Telaranta classification: the importance of different procedures for different indications in sympathetic surgery. Ann Chir Gynaecol. 2001;90:161–166[Medline]
12. Chung IH, Oh CS, Koh KS, et al. Anatomic variations of the T2 nerve root (including the nerve of Kuntz) and their implications for sympathectomy. J Thorac Cardiovasc Surg. 2002;123:498–501[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) 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): Doo Yun Lee Hyo Chae Paik Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lee, D. Y. Articles by Paik, H. C. Search for Related Content PubMed PubMed Citation Articles by Lee, D. Y. Articles by Paik, H. C. Related Collections Mediastinum