| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2006;81:1227-1233
© 2006 The Society of Thoracic Surgeons
a Medical City Dallas Hospital, Dallas, Texas
b Cardiopulmonary Research Science and Technology Institute, Dallas, Texas
Accepted for publication November 3, 2005.
* Address correspondence to Dr Herbert, Medical City Dallas Hospital, 7777 Forest Lane, Ste C-740, Dallas, TX 75230 (Email: morley.herbert{at}hcahealthcare.com).
Presented at the Forty-first Meeting of The Society of Thoracic Surgeons, Tampa, FL, Jan 24–26, 2005.
 |
Abstract |
|---|
 Top Abstract IntroductionPatients and MethodsResultsCommentDiscussionReferences |
|---|
METHODS: All procedures were performed thoracoscopically using bilateral 3 mm ports and excision of a segment of the sympathetic chain by electrocautery. The level of sympathectomy depended upon clinical symptoms: T2 for face/scalp, T3 for palmar hyperhidrosis, and T4 for axillary hyperhidrosis, or a combination of levels for multiarea sweating. All patients were followed-up at least 1 year postprocedure by mail questionnaire and/or telephone.
RESULTS: Two hundred twenty-two patients had undergone thoracoscopic sympathectomy for essential hyperhidrosis between Jan 1, 2002 and Nov 30, 2003, with 170 patients having at least one-year follow-up. The patients' preoperative assessment of the severity of sweating in the affected areas was compared with their one-year evaluation in order to determine the durability of the procedure. All affected areas continued to show significant improvement in sweating as compared with preoperative symptoms. Compensatory sweating was reported in 85% of our patients at one-year follow-up. Patients with a T2 lesion were significantly more likely to have severe compensatory sweating than those with other levels; 48.8% vs 16.1% (p < 0.001). Patients with levels other than T2 reported high degrees of satisfaction unrelated to their postoperative compensatory symptoms.
CONCLUSIONS: Patient satisfaction and perceived effectiveness with sympathectomy for palmar or axillary hyperhidrosis remain high even one year after the procedure. Inclusion of the T2 lesion results in significantly more severe compensatory sweating and reduced satisfaction than other levels.
|
Introduction |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
|---|
This condition can be socially, psychologically, and professionally stigmatizing in the most affected patients. The manifestation of excessive localized sweating generally occurs either spontaneously, or in association with stressful or emotionally charged situations. Patient symptoms generally begin in childhood or early adolescence, around the time of puberty, and rarely improve with age. Severely affected patients have been known to refuse professional advancement if the resulting promotion would increase the likelihood of exposing their condition.
Surgical treatment for hyperhidrosis has been described as early as the 1920s, primarily utilizing a thoracotomy approach [2]. This aggressive approach was associated with significant patient morbidity and a protracted recovery period and failed to generate widespread support. Medical management of hyperhidrosis has been poorly effective, often leading many patients to try multiple unsuccessful treatment modalities. Advances in video-assisted thoracoscopic surgery, utilizing microinstrumentation, have allowed surgical sympathectomy to become a viable first-line therapy for hyperhidrosis. We have previously reported good early results with thoracoscopic sympathectomy utilizing a surgical technique of excision of the sympathetic ganglia at the level of the second rib for facial/scalp sweating, the third rib for palmar sweating, and the fourth rib for axillary sweating [3]. Multiple areas of excision were employed for multilevel sweating. The early results were promising, but continuing efficacy and patient satisfaction were unknown. To evaluate the durability of this surgical approach for hyperhidrosis, we retrospectively reviewed the results of patients at least one year out from time of surgery.
|
Patients and Methods |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
|---|
|
|
Operative Technique
All procedures are performed under general anesthesia using a double lumen endotracheal tube for isolated lung ventilation and with the patients supine with their arms extended. A radial arterial line is always placed for continuous blood pressure monitoring. Three 3 mm incisions are performed in the right inframammary crease with the most medial directly below the areola and the most lateral near the tail of the breast. Three sealed thoracoscopic ports are then placed, and carbon dioxide (CO2) insufflated to aide in exposure of the sympathetic chain. Maximum insufflation pressure is set for less than 8 mm Hg in order to avoid mediastinal shift and hypotension. A 30 degree, 3 mm endoscope is inserted into the center port, and a small curved grasping instrument and a monopolar hook cautery inserted into the other ports. The chest wall is then meticulously inspected and the first rib identified. The lower level ribs are then identified based on the position of the first rib and a cautery score placed on the body of the third rib to mark it's location. This is done to ensure that we can always correctly identify the appropriate level of transection, as it is easy to become disoriented with the small visual field associated with a 3 mm endoscope. The sympathetic chain is then identified and the parietal pleura opened over the nerve at the selected ganglion level. We excise a very small segment of the T2 ganglia for patients with face/scalp hyperhidrosis, T3 for palmar symptoms, and the T4 ganglion for patients with axillary hyperhidrosis. When treating patients for more than one area, multiple segments are excised, while the rest of the chain is left intact. If accessory fibers and the Kuntz nerve are found, they are ablated with the cautery. Local anesthetic using 0.25% Marcaine with epinephrine is then instilled into the sympathectomy bed to decrease postoperative pain. The CO2 is then evacuated from the chest with a small catheter under water seal as the lung is gently reinflated. The port sites are closed with skin glue and the contralateral side performed in a similar fashion. Patients are then observed in the post anesthesia care unit, and ultimately discharged home generally within 2 to 3 hours after the procedure. Routine chest x-rays in the recovery area are not performed.
Data Collection
All initial patient questionnaires collected at the group seminar are entered into a customized database at the time of the procedure. Patients are routinely followed with an office visit at three weeks after surgery and then on a yearly basis either by telephone or through the mail. The long-term data collected include postoperative complications including the severity of compensatory symptoms, late satisfaction with the procedure, and incidence of symptom recurrence. Data were stored in a database and exported to SAS (v9.1.3, SAS Institute, Cary, NC) for analysis. The 
2 statistics, means, standard deviations, and t-tests were used as appropriate.
|
Results |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
|---|
One year postoperative questionnaires were returned by 170 (76.6%) of the 222 treated patients. The mean time from operation to follow-up was 1.2 ± 0.3 years. Patients were asked to evaluate their one-year satisfaction with the procedure on a scale of 0 to 10 with 10 being the highest degree of satisfaction. This was then converted to a satisfaction rating based on patient response with scores of 0–2 classified as very dissatisfied, 3–7 as satisfied, and 8–10 as very satisfied. The most satisfied patients were those that had sympathectomy for palms only, palms and axilla, and axilla alone (see Fig 1). Patients with the highest degrees of dissatisfaction were those that had a T2 level excision as isolated treatment of face/scalp hyperhidrosis, or T2 in conjunction with any other level being performed [Fig 1]. Additionally, the patients' preoperative assessment of the severity of sweating in their affected areas was compared with their one-year evaluation in order to determine the durability of the procedure (Table 3). All affected areas continued to show significant improvement in sweating as compared with preoperative symptoms. Although we did not surgically treat sweating of the feet, an estimated 50% to 75% of the patients who had surgery directed to palmar sweating alone, or in conjunction with other areas, noted significant improvement in sweating of their feet as evidenced by their scores.
|
|
The scores were then converted to a rating based on patient response with scores of 0 classified as no compensatory symptoms, 1–4 classified as mild symptoms, 5–7 as moderate, and 8–10 as severe compensatory symptoms. Patients having sympathectomy for face/scalp alone and face/scalp, palms, and axilla reported the highest rates of severe compensatory sweating at 63% and 56%, respectively [Fig 2]. Conversely, patients having T4 excisions for only axillary symptoms, or T3 excisions for isolated palmar sweating, reported the lowest incidence of severe compensatory sweating at 0% and 11.1%, respectively [Fig 2]. The most frequent areas involved with compensatory sweating were the chest and back, legs, abdomen, thighs, and groin area. A univariate analysis was performed comparing operative excision levels including T2 versus those procedures that did not have a T2 excision for the frequency of mild, moderate, and severe compensatory hyperhidrosis. Patients having the T2 ganglia excised as part of their procedure were significantly more likely to have severe compensatory symptoms as compared with patients not having T2 removed; 48.8% vs 16.1% (p < 0.001) [Fig 3].
|
|
|
|
Comment |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
|---|
Compensatory sweating continues to be the most common side effect of thoracic sympathectomy, and was reported in 85% of our patients. Nevertheless, the reported incidence of compensatory sweating after sympathectomy varies throughout the literature. Zacherl and colleagues [5] report an incidence of only 69% in a series of 352 patients. In contrast, Fredmann and colleagues [16] reported that 90% of their patients had compensatory sweating postoperatively. This variability likely reflects the heterogeneity of the patient populations, as well as the variability in surgical technique, patient follow-up, and classification of compensatory sweating. Accurately defining compensatory sweating into quantifiable categories remains a challenge due to the subjectivity of the symptom. It has also been noted that the frequency of patients' reporting of compensatory symptoms is highest in the summer and lowest in the winter. Therefore, geographical differences between reporting centers likely also plays a role in reported frequency of compensatory sweating. Gustatory hyperhidrosis, while a recognized side effect after thoracic sympathectomy, was not a significant finding in this population. The trigger for eliciting gustatory hyperhidrosis is thought to be the consumption of spicy or acidic foods [10]. The etiology of this symptom is unclear, but Hashmonai and colleagues [17] speculate that it may be a result of the ingrowth of vagal nerve fibers into the severed sympathetic chain.
It has been hypothesized that compensatory sweating is a thermoregulatory mechanism by which the sweat glands attempt to compensate for a decreased amount of secretory tissue [18]. Using Berkow's surface area formation, Shally and Florence [19] demonstrated that sweat gland function diminished as much as 40% after sympathectomy. Secondarily, many authors felt that compensatory symptoms could be reduced or eliminated by limiting the extent of sympathetic nerve excision. This study demonstrates that while the frequency of compensatory sweating may not be reduced, the severity of those symptoms can be correlated to both the level and extent of resection. Our results demonstrate that compensatory sweating is significantly more likely to be severe in those patients who had the T2 ganglia excised. Additionally, there was also a strong correlation between the number of levels excised and the degree of compensatory sweating. The more sympathetic segments excised, especially those including T2, the greater the incidence of severe compensatory symptoms. These results were consistent with the findings that the most satisfied patients at one-year follow-up were those who did not have a resection of the T2 ganglion. The only exception would be those patients who had a T3 resection for palmar symptoms in addition to the T2 resection for facial/scalp sweating. This is probably due to the fact that palmar hyperhidrosis is the most socially and professionally inhibiting, and removal of this problem overshadows the discomforts associated with compensatory sweating.
Based on these findings, we currently limit the extent of our resections for hyperhidrosis to a single level if possible in order to reduce the incidence of severe compensatory symptoms. In the event that patients have severe multisite sweating, or if sweating involves the face/scalp and would require a T2 resection, we would recommend detailed counseling of the patient in regards to the increased likelihood of experiencing severe compensatory sweating.
Hederman [20] stated that the most grateful patients that surgeons will ever encounter are those who have been cured of professionally or socially inhibiting sweating by sympathectomy. However, long-term patient satisfaction with the procedure is ultimately dependent upon a perception of few or manageable postoperative side effects once the euphoria over improvement in their hyperhidrosis dissipates. This report demonstrates a clear correlation between the severity of compensatory symptoms and the level and extent of ganglionic resection. Therefore, it is important to continue to develop technical refinements in the procedure in order to minimize postoperative complications.
|
Discussion |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
|---|
DR DEWEY: Thank you. We would recommend trying to avoid T2 level resections if at all possible. I think there are a lot of people and there are a lot of results published in the literature where people routinely resect T2 and still get good results. I think, though, if you talk to patients one year after resection when the euphoria of the reduction of their sweating is gone, the thing they most focus on is their compensatory symptoms. So because this is an elective procedure and long-term patient satisfaction is probably going to be predicated upon how bad their compensatory symptoms are, we have elected in our practice to try and not routinely resect T2, or if we do, we spend much more time detailing and counseling the patients that they can expect a fairly significant risk of compensatory symptoms.
DR MARK J. KRASNA (Baltimore, MD): Todd, that was an excellent presentation. As you know, Mike and I started about, I guess, 11 years ago doing this the same way, which is the three-incision approach and excision. In '93 when I returned from some time I spent with Dr Claes in Sweden, I was converted to his single-incision technique. And probably in addition to the fact that my single 7 mm incision is smaller than your three 3 mm incisions, more importantly, I think that it is not necessary to resect or excise as opposed to just cut the nerve. So one of the questions I'd like to ask is, is it possible that your high incidence of compensatory sweating with T2, which is actually counter to what some people around the world have found, may be related to the difference in your technique? Our recent series from my colleagues and I in Maryland, on over 396 cases, had only a 2% severe compensatory sweating rate, although about 40% had some. We no longer resect it. We do cut T2 as well as the nerve of Kuntz, but we didn't see that high a degree of severe compensatory sweating.
My second question obviously gets to the statistics. I actually enjoyed the graphs because it does help sort things out. The total number of patients didn't have complete follow-up. When you go back to your original group, and I think you guys have over 280 by now, is this in fact something that you're seeing across the board? Is it something that's dependent on the level that you cut or is it possible that this is simply dependent on the disease with which the patients present? Is it that someone who shows up with a disease that requires T2 to be cut perhaps is more predisposed to compensatory sweating, whether it's because of differences in counseling; psychological or otherwise? I enjoyed the paper.
DR DEWEY: I think those are all good questions. I think if you ask 5 guys who do sympathectomy for hyperhidrosis, you're going to get 5 opinions on the levels that should be done and how it should be done. If you read the literature, you'll find people who cut the nerve, people who resect the nerve, and people who put clips on the nerve, feeling that potentially you could reverse the operation if the patients return with severe compensatory symptoms. I think that these patient populations are a mixed bag and I think that it's hard to quantify objectively a subjective symptom. We have found in our experience that our complaints of compensatory symptoms are worse in the summer and not quite so bad in the winter, and we also found that our complaints of compensatory symptoms really have to do with personality type as well. This attempt was really to try and reinforce what our subjective opinion is, not only preoperatively seeing the patients but our postoperative complaints. The people who have severe compensatory symptoms, you'll know about it because they will be calling you every week for the rest of their life. So because this is an elective procedure, our focus really is to minimize the complications of the elective procedure while trying to do the most benefit. And I think only time will tell as to whether cutting or clipping or excising is the best, and the only way to know is to accrue a large enough patient population where we can objectively look at it.
DR M. BLAIR MARSHALL (Washington, DC): I have a few questions. One, I'm surprised that you operate on patients without having them have some form of treatment beforehand. Could you comment on that? I think in one of the Asian countries, recently, they made it illegal to do a sympathectomy on patients less than 20 because of potential adverse effects. Many of these patients are very young and one could actually ruin their lives. Do you insist that these patients fail some type of initial therapy?
My second question is: There's some data to suggest that this procedure decreases the heart rate of patients by 10%. Did you look for this and do you offer this procedure to athletes? Lastly, do you think that the degree of compensatory sweating is proportional to the amount of preoperative sweating and have been able to examine this?
DR DEWEY: Thank you. I think if there was a good nonsurgical treatment, we would be willing to try that. In our experience, the topical agents, the oral anticholinergics, the beta-blockers have not been effective, and, in fact, the side effects of those treatments are often worse than the hyperhidrosis itself. I think Botox is effective. A lot of people's insurance plans won't pay for it, and it's about $500 per treatment. So it's tough to get people to pay $500 out of their pocket when their insurance company will actually support a treatment which we feel is very efficacious.
We do look at heart rate control in patients, and a couple years ago we did a study where we measured, basically, exercise performance in people preoperatively and postoperatively, and I think we subjectively saw that there was a small decrease in heart rate, but we couldn't quantify it. I think our approach would be, if we have an athlete or, say, an Olympic-caliber athlete in which aerobic capacity is a major function of their ability to compete, especially in sports where the degree of separation between first and second is in microseconds, we would probably counsel those patients to wait until after they are done competing prior to having a sympathectomy.
|
References |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  B. Weksler, M. Pollice, Z. B.B. Souza, and R. Gavina Comparison of ultrasonic scalpel to electrocautery in patients undergoing endoscopic thoracic sympathectomy. Ann. Thorac. Surg., October 1, 2009; 88(4): 1138 - 1141. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
V. Ambrogi, E. Campione, D. Mineo, E. J. Paterno, E. Pompeo, and T. C. Mineo Bilateral thoracoscopic t2 to t3 sympathectomy versus botulinum injection in palmar hyperhidrosis. Ann. Thorac. Surg., July 1, 2009; 88(1): 238 - 245. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. Sugimura, E. H. Spratt, C. G. Compeau, D. Kattail, and Y. Shargall Thoracoscopic sympathetic clipping for hyperhidrosis: Long-term results and reversibility. J. Thorac. Cardiovasc. Surg., June 1, 2009; 137(6): 1370 - 1378. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Y. Liu, J. Yang, J. Liu, F. Yang, G. Jiang, J. Li, Y. Huang, and J. Wang Surgical treatment of primary palmar hyperhidrosis: a prospective randomized study comparing T3 and T4 sympathicotomy Eur. J. Cardiothorac. Surg., March 1, 2009; 35(3): 398 - 402. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. A. Tetteh, S. S. Groth, T. Kast, B. A. Whitson, D. M. Radosevich, A. C. Klopp, J. D'Cunha, M. A. Maddaus, and R. S. Andrade Primary Palmoplantar Hyperhidrosis and Thoracoscopic Sympathectomy: A New Objective Assessment Method Ann. Thorac. Surg., January 1, 2009; 87(1): 267 - 275. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. M. Rodriguez, J. L. Freixinet, M. Hussein, J. M. Valencia, R. M. Gil, J. Herrero, and A. Caballero-Hidalgo Side effects, complications and outcome of thoracoscopic sympathectomy for palmar and axillary hyperhidrosis in 406 patients Eur. J. Cardiothorac. Surg., September 1, 2008; 34(3): 514 - 519. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
X. Li, Y.-R. Tu, M. Lin, F.-C. Lai, J.-F. Chen, and Z.-J. Dai Endoscopic Thoracic Sympathectomy for Palmar Hyperhidrosis: A Randomized Control Trial Comparing T3 and T2-4 Ablation Ann. Thorac. Surg., May 1, 2008; 85(5): 1747 - 1751. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Baumgartner and J. Konecny Compensatory Hyperhidrosis After Sympathectomy: Level of Resection Versus Location of Hyperhidrosis Ann. Thorac. Surg., October 1, 2007; 84(4): 1422 - 1422. [Full Text] [PDF]
|
|
|
|
 |
|
 G. Rocco Endoscopic VATS sympathectomy: the uniportal technique MMCTS, May 7, 2007; 2007(0507): 323. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Y.-R. Tu, X. Li, M. Lin, F.-C. Lai, Y.-P. Li, J.-F. Chen, and J.-G. Ye Epidemiological survey of primary palmar hyperhidrosis in adolescent in Fuzhou of People's Republic of China Eur. J. Cardiothorac. Surg., April 1, 2007; 31(4): 737 - 739. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Reisfeld One-Year Follow-Up After Thoracoscopic Sympathectomy for Hyperhidrosis Ann. Thorac. Surg., January 1, 2007; 83(1): 358 - 359. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
