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Ann Thorac Surg 2005;80:1063-1066
© 2005 The Society of Thoracic Surgeons

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Original article: General thoracic

Clinical Experience in 397 Consecutive Thoracoscopic Sympathectomies

Department of Surgery, Division of Thoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland

Accepted for publication March 18, 2005.

^_* Address reprint requests to Dr Kwong, Division of Thoracic Surgery, University of Maryland School of Medicine, 22 S Greene St, Rm N4E35, Baltimore, MD 21201 (Email: kkwong{at}smail.umaryland.edu).

Presented at the Fiftieth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 13–15, 2003.

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Discussion References

 
BACKGROUND: The purpose of this study is to evaluate the safety and efficacy of thoracoscopic sympathectomy for the treatment of hyperhidrosis, blushing, reflex sympathetic dystrophy, and digital ischemia.

METHODS: We conducted a retrospective review of 202 patients who underwent thoracoscopic sympathectomy at the University of Maryland from March 1992 to April 2003.

RESULTS: Three hundred ninety-seven procedures were performed on 202 patients (105 women, 97 men). Mean age was 29 years (range, 9 to 65). Indications for surgery included hyperhidrosis, facial blushing, digital ischemia, and reflex sympathetic dystrophy. Synchronous bilateral sympathectomies were performed in 194 patients; right side alone (n = 6); left side alone (n = 1); 1 patient had staged bilateral sympathectomies. Single incision with lung isolation technique was used. There was no mortality. Preoperative symptoms resolved completely or significantly improved in greater than 90% of patients. One patient with reflex sympathetic dystrophy recurred and 1 patient with hyperhidrosis complained of significant compensatory sweating. Compensatory sweating to a lesser degree occurred in approximately one third of patients. Complications included asymptomatic pleural effusion (n = 1), pneumothorax (n = 1), and reoperation for chylothorax that was identified early (n = 1). In 2 patients treated for facial blushing, Horner’s syndrome developed postoperatively; 1 of them subsequently underwent blepharoplasty. In 3 patients, hyperesthesias developed at the incision.

CONCLUSIONS: Thoracoscopic sympathectomy can be performed safely and with excellent results. Compensatory sweating is the main side effect, although significant complaints from this are rare. Horner’s syndrome remains an extremely uncommon complication as a result of thoracoscopic sympathectomy at our institution.

	Introduction

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Minimally invasive thoracic surgery has evolved significantly over the last decade and has become a mainstay in the technical repertoire of the modern thoracic surgeon. Division of the thoracic sympathetic nerves, or dorsal thoracic sympathectomy, has been described for treatment of a wide array of disorders including relief of hyperhidrosis, facial blushing, and reflex sympathetic dystrophy among other indications. Although large series have been reported from Europe or the Far East, few such reports have originated from North America. In this paper, we reviewed the data of one North American academic institution performing large volumes of video-assisted thoracic surgery procedures to analyze the indications, success, and safety of thoracoscopic sympathectomy.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Discussion References

 
Data of all patients undergoing thoracoscopic sympathectomy from June 1992 through April 2003 at the University of Maryland Medical Center were retrospectively reviewed (as approved by the Institutional Review Board of the University of Maryland, Protocol H-23746). All patients underwent routine office follow-up 2 to 6 weeks after operation. In rare cases, when the patient resided some distance from our medical center, follow-up was obtained by telephone or written questionnaires. At 6 months or longer after operation, patients underwent further telephone follow-up questionnaire to determine changes, if any, in postoperative results. Information collected for analysis included indication for surgery, patient age and sex, side of operation, length of stay, and complications. The response to surgical treatment was also defined with a quality of life index (iQOL) scaled from 0 to 3. An iQOL = 0 meant symptoms did not affect the patient’s quality of life; an iQOL = 1 meant that symptoms affected QOL only minimally; an iQOL = 2 reflected moderate effect, and iQOL = 3 represented major/significant effect on the patient’s quality of life. An iQOL was ranked for each patient both before and after operation. Recurrences of symptoms or compensatory changes were also noted.

Three hundred ninety-seven thoracoscopic sympathectomies were performed in 202 patients. There were 97 men and 105 women. The mean age was 29 years (range, 9 to 65). Synchronous bilateral sympathectomies were performed in 194 patients; right side alone in 6 patients; left side alone in 1 patient; and 1 patient had staged bilateral sympathectomies. Indications for surgery included hyperhidrosis (n = 175), facial blushing (n = 21), Raynaud’s (n = 3), upper extremity digital ischemia (n = 2), and reflex sympathetic dystrophy (n = 1). All patients offered surgery were previously deemed intolerant or failed medical therapy for their symptoms.

General anesthesia using single lung isolation technique with a double-lumen endotracheal tube was used in all patients. The patients were positioned in the semi-Fowler’s position with the arms abducted. A single 10-mm thoracoscopic port, situated just lateral to the pectoralis muscle, was used for each side of operation. All patients underwent division of their sympathetic chain using controlled intermittent electrocautery. The sympathetic chain was divided at levels T2 and T3 for palmar hyperhidrosis, upper extremity digital ischemia, reflex sympathetic dystrophy, and Raynauds; and a high T2 division was performed for facial blushing. The T3 and T4 levels were divided for isolated axillary hyperhidrosis. Postoperative chest tubes were not used routinely. A temporary intraoperative pediatric chest tube is inserted into the chest during closure of the incisional soft tissues but is removed before tying the skin closure suture. All intrapleural air is evacuated by the temporary chest tube after the anesthesiologist places a Valsalva maneuver upon the patient. A postoperative chest roentgenogram is routinely obtained in the recovery room to verify the absence of a significant pneumothorax. The majority of our operations were performed on an outpatient surgery basis. Hospitalization was not necessary for the majority of patients because recovery was quick, and there is minimal debilitation after this minimally invasive operation.

	Results

Top Abstract Introduction Patients and Methods Results Comment Discussion References

 
There was no mortality. No operation needed conversion to open thoracotomy. Complications included asymptomatic pleural effusion (n = 1), pneumothorax (n = 1), and reoperation for chylothorax that was identified early (n = 1). Two patients treated for facial blushing developed Horner’s syndrome postoperatively; 1 of them subsequently underwent a blepharoplasty. Three patients developed hyperesthesias at the incision. The overall major complication rate was 2.4% (n = 5 of 202). The majority of these complications occurred in the early years of the program. The mean follow-up for this cohort was 13 months.

Compensatory sweating of any degree was found in 40% of the patients (n = 81 of 202). However, the overwhelming majority of these patients rated their compensatory sweating as minimal and rated the overall impact of compensatory sweating on their quality of life as negligible.

Of the 202 patients, 157 patients who were treated for hyperhidrosis had complete preoperative and postoperative information regarding patient perception of symptoms as it related to quality of life and overall satisfaction with the results of the operation (Figs 1 and 2). Preoperatively, the majority of these patients experienced moderately debilitating to severely debilitating hyperhidrosis (mean preoperative iQOL = 2.1 ± 0.4). Postoperatively, the mean iQOL improved to 0.4 ± 0.7. Overall, 91.7% (n = 144 of 157) had an improvement in their quality of life after thoracoscopic sympathectomy.

View larger version (20K): [in this window] [in a new window]   Fig 1. Hyperhidrosis patients: preoperative quality of life (QOL) index (0 = excellent QOL, no effect; 1 = minimal effect on QOL; 2 = moderate effect on QOL; 3 = significant/severely affects QOL).

	Comment

Top Abstract Introduction Patients and Methods Results Comment Discussion References

Surgical treatment for hyperhidrosis has evolved significantly in the last 2 decades. Specific advances in technology have made operative approaches such as the dorsal and supraclavicular approaches mainly historical interests. Currently, the main approach to the thoracic sympathetic chain is by minimally invasive thoracoscopic surgery. Our current series of patients described here were all treated with this modern operative approach . Of note, the term "sympathectomy" historically referred to extirpation or destruction of the sympathetic ganglia and chain, and the term "sympathicotomy" meant severing the sympathetic chain. Modern day usage by the lay public has extended the term thoracic sympathectomy to include the latter operative technique as well because from a functional perspective the two technical approaches produce the same desired effects. Although early in our experience a standard three-port sympathectomy with resection of the sympathetic chain was employed, we have predominantly employed the sympathicotomy technique of "sympathectomy" for hyperhidrosis, as described here in this current series, because sympathicotomy allowed for fewer incisions, less external and internal tissue trauma, while producing equivalent clinical results. Furthermore, the operation has evolved into one well suited for the outpatient setting. Although early experience involved overnight hospitalization for monitoring a patient’s recovery process, this operation has demonstrated extreme safety and patient clinical stability postoperation. Thus, the majority of patients in this series undergo this operation on an outpatient status, similar to the experience of other surgical centers.

There is currently no clinical consensus regarding the optimum levels of sympathetic nerve division with respect to the patient’s preoperative symptoms. Although early reports are now emerging supporting the division of single levels or the use of surgical clips to treat isolated palmar or axillary hyperhidrosis, long-term data from well-controlled, randomized clinical trials to evaluate these issues are still lacking. The evolution of thoracoscopic sympathicotomy, as a procedure whereby the nerve is divided at two levels, effectively mimics the historical operation in which a segment of the nerve is resected. At present, this approach of sympathicotomy appears to be the standard.

The results seen at our institution compare favorably with those of previously published large series [3–19]. The significant improvement in the QOL index, seen in more than 90% of our patients, is perhaps a reflection of careful patient selection for surgical treatment. The majority of our patients who are offered surgery have had a long-standing history of hyperhidrosis symptoms and have tried on average at least two medical treatments in the past without any alleviation of symptoms. However, the objective findings of completely dry hands in a majority of our patients at postoperative follow-up recapitulates the same findings in those treated at other centers internationally; as such, there is now substantial experience demonstrating the high efficacy of surgical treatment for hyperhidrosis. Similar quality of life assessment results have been shown by others [20, 21].

Complications were relatively rare in our series, and the majority of those occurred in the early years of the hyperhidrosis program. Compensatory sweating is the most common side effect seen in our series, as is also uniformly found in other series as well. Our incidence of compensatory sweating is within the range of previous reports [5, 6, 12–15]. Interestingly, there appears to be a much higher incidence of compensatory sweating in the reports from Asian countries compared with those of Western countries. The incidence of compensatory sweating is between 40% and 60% in the Western countries compared with 80% and 90% in the Asian countries. In one Asian review, it has even been reported as high as 97% [11]. The reasons for this discrepancy are unknown. We have observed that compensatory sweating can be exacerbated by warmer temperatures and humid weather—conditions more prevalent in the Asian countries. Our incidence, which is in the lower end of the quoted range, may be a result of our being able to identify patients with sweating in nonclassical hyperhidrosis body regions preoperatively through detailed preoperative histories. In a sizeable subset of patients, this in-depth inquiry reveals some mild degree of sweating in the same body areas traditionally where postoperative compensatory sweating might be found. Therefore, postoperative sweating in these same preoperative affected areas should not be regarded as compensatory sweating, because the patient already has a propensity to sweat in those areas before surgery. It is only rarely that a patient will suffer a severe form of compensatory sweating to the degree that these new symptoms affect them more profoundly than the preoperative hyperhidrosis symptoms. Therefore, we take great care to caution our patients who are considering surgery about this rare but unpreventable scenario.

Horner’s syndrome is a dreaded potential complication of thoracic sympathetic chain surgery. Fortunately, this is rarely found in most centers with extensive experience performing these procedures. In our series, the overall incidence of postoperative Horner’s is 0.5% (2 unilateral Horner’s, of 397 procedures). The 2 patients who experienced postoperative Horner’s were undergoing operation for treatment for facial blushing, not hyperhidrosis. The indicated technique for treatment of this condition mandates severing the sympathetic chain, at a level just below the stellate ganglion. Logically, the risk of developing Horner’s for surgical treatment of facial blushing could be expected to be higher for facial blushing than that for treatment of hyperhidrosis. Our low incidence of this complication compares highly favorably, as the incidence of Horner’s has been often reported in the 1% to 2% range, although as high as 17% has also been reported in one center [7].

In this article, we endeavored to report the results of the thoracoscopic sympathectomy surgery experience in one North American academic institution. From our results, we believe that thoracoscopic sympathectomy can be performed safely and with excellent results. Compensatory sweating is the main side effect, although the majority of these instances are well tolerated and patients remain overwhelmingly pleased with the surgery because of significant alleviation or elimination of their preoperative symptoms. Horner’s syndrome remains an extremely uncommon complication as a result of thoracoscopic sympathectomy at our institution.

	Discussion

Top Abstract Introduction Patients and Methods Results Comment Discussion References

 
DR HAROLD C. URSCHEL, JR (Dallas, TX): I would like to compliment Drs Kwong and Krasna and their group on an excellent presentation. This is one of our most gratifying operations, and I think to have it as an outpatient procedure is excellent.

We have had the experience with several thousand of these for the same reasons that Dr Kwong presented, in addition to traumatic thoracic outlet syndrome and Raynaud’s disease. In the latter, we remove the stellate ganglion to produce a Horner’s, in the others we only remove two or three ganglia. We used 5-mm ports rather than 10, no CO₂, depending only on the double-lumen tube to deflate the lung. If the hand temperature increases 1 degree during the procedure, it assures the surgeon of an adequate sympathectomy.

The Scandinavians don’t have to remove a specimen for legal reasons like we do. Doctor Mike Mack and Dan Meyers have also made significant contributions to this technique. Thank you.

DR KWONG: I thank Dr Urschel for his comments and his numerous contributions to this field. We have explored the option of using 5-mm ports, and interestingly, we do not see a great difference except that you may need to use multiple 5-mm ports rather than a single 10-mm port as we use routinely. There have been one or two papers that have compared the differences between 5-mm and 10-mm ports in this operation, but significant differences were not observed. We do not use a hand temperature probe as some of the Asian groups have done in the past. The results of this surgery are seen almost immediately—if not immediate, then almost always equilibrated within 24 to 48 hours. So fairly soon after the operation, you know if this operation has worked to relieve symptoms and that it was a good operation for the patient.

As far as taking a piece of the chain out for proof, I think with modern day technologies, with digital videos and everything, one might even contemplate doing videos of this to show your operation, thus perhaps sparing the need for sending a pathologic specimen.

DR SCOTT W. ARNOLD (Roanoke, VA): That was a great paper, and I have just a quick question. Are you and Dr Krasna currently advocating then, just to be clear, are you still just doing a T2-T3 en bloc sympathectomy or are you now advocating just doing a simple sympathicotomy, just dividing at T2, just a simple division, rather than taking T2 and T3 out as a bloc?

DR KWONG: Yes, in this series of patients the description is exactly just that. The lay public and the medical literature nowadays not infrequently use the term sympathectomy to refer to the functional equivalent of whatever operation you do to produce the effects of a sympathectomy operation. So in the past, some people have resected the ganglion or a piece of the chain. Our long-standing and still favored procedure is sympathicotomy. We divide the levels at T2 and T3 for hyperhidrosis and for some of the other indications. For facial blushing, we do a high T2 sympathicotomy. I believe ours is actually a fairly respectable North American series demonstating the efficacy of this technique. Large series from Europe as well as Asia have also shown similar highly effective results using sympathicotomy.

View larger version (17K): [in this window] [in a new window]   Fig 2. Hyperhidrosis patients: postoperative quality of life (QOL) index (0 = excellent QOL, no effect; 1 = minimal effect on QOL; 2 = moderate effect on QOL; 3 = significant/severely affects QOL).

	References

Top Abstract Introduction Patients and Methods Results Comment Discussion References

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