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a Division of Thoracic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
b Division of Thoracic Surgery, St. Joseph Medical Center, Towson, Maryland
Accepted for publication August 1, 2007.
* Address correspondence to Dr Kwong, Division of Thoracic Surgery, University of Maryland School of Medicine, 22 S Greene St, Room N4E35, Baltimore, MD 21201 (Email: kkwong{at}smail.umaryland.edu).
Presented at the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.
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Abstract |
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Methods: Six hundred eight thoracoscopic sympathicotomies were performed in 304 patients. Retrospective stratified analysis of patients after thoracoscopic sympathicotomy for hyperhidrosis or facial blushing and having completed follow-up of at least 6 months (n = 232) was performed. Preoperative and postoperative quality-of-life indices (range, 0 to 3) were used to measure impact of surgery, and comparisons were indexed to preoperative symptoms. Postoperative compensatory sweating was analyzed with respect to the level(s) of sympathetic chain division.
Results: Thoracoscopic sympathicotomy was performed at level T2 alone in 5% of patients; levels T2 to T3 in 63% of patients; levels T3 to T4 in 3% of patients; levels T2 to T4 in 14% of patients; and more than three levels in 14% of patients. In hyperhidrosis patients, mean preoperative quality-of-life index was 2.0 and postoperative quality-of-life index was 0.4 (p < 0.001). Facial blushers had preoperative and postoperative quality-of-life index of 2.6 and 1.0, respectively. Significant compensatory sweating was seen in 33% patients overall and occurred in 29% of patients with palmar symptoms, 26% of axillary patients, and 42% of facial blushers. Significant compensatory sweating in relation to the level(s) of sympathetic chain division occurred in T2 alone, 45%; T2 to T3, 30%; T3 to T4, 14%; T2 to T4, 38%; and more than three levels, 49%.
Conclusions: Significant improvement in quality of life can result from surgery for hyperhidrosis. However, the incidence of postoperative compensatory sweating may be dependent on the level of sympathicotomy performed. The choice of sympathicotomy level(s) should be directed toward reducing the incidence of significant compensatory sweating while simultaneously ensuring relief of primary preoperative symptoms.
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Introduction |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionReferences |
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Material and Methods |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionReferences |
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We performed 608 thoracoscopic sympathicotomies in 304 patients. There were 172 women and 132 men. The mean age was 28.6 years (range, 9 to 65 years). At the time of analysis, 232 patients were 6 months or greater after surgery and had immediate postsurgical and 6-month postoperative complete data sets to permit comparison analyses. Of the patients excluded from this current analysis, 38 of the 304 patients were not yet at 6 months after operation and therefore did not have complete data sets yet. Since 1992, only 34 patients have been lost to the postoperation 6-month follow-up. Synchronous bilateral sympathicotomies were performed in all patients. 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. Details of our surgical technique have been previously described [8]. To summarize in brief, the patients are positioned into semi-Fowler’s position with the arms abducted. A single 10-mm thoracoscopic port, situated just lateral to the pectoralis musculature, is used for each side of the 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. A high T2 division in conjunction with a lower stellate ramicotomy was performed for facial blushing. T3 and T4 levels were divided for isolated axillary hyperhidrosis. The combined symptoms of palmar and axillary hyperhidrosis were treated with sympathicotomies at levels T2 through T4. Early in our clinical experience, a small group of patients underwent sympathicotomies of greater than three levels in an attempt to relieve pedal symptoms in addition to hyperhidrosis elsewhere, but that is no longer our standard practice.
A temporary intraoperative pediatric chest tube is inserted into the chest during closure of the incisional soft tissues but is removed before tying down the skin closure suture. All intrapleural air is evacuated through the temporary chest tube while the anesthesiologist holds both lungs in a Valsalva maneuver. A postoperative chest roentgenograph is obtained in the recovery room to verify the absence of a significant pneumothorax. The vast majority of our operations were performed on an outpatient surgery basis. Overnight hospitalization was used in only a small handful of patients at the beginning of our clinical experience with this operation in the early 1990s. Barring other medical indications, we have been conducting this operation without any routine hospitalization.
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Results |
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In all patients, there were no intraoperative complications or perioperative mortality. All operations were completed thoracoscopically and none required conversion to open thoracotomy. Postoperative 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 exhibited Horner’s syndrome postoperatively (0.65% incidence); one of them subsequently underwent a blepharoplasty. Three patients experienced hyperesthesias at the incision. Overall major complication rate was 2.2% (n = 5 of 232). These complications occurred in the early years of our clinical experience with this operation. No additional perioperative complications have been encountered recently in the last 110 patients.
On the basis of preoperative symptoms, thoracoscopic sympathicotomy was performed at the T2 level alone in 5% of patients, levels T2 and T3 in 63% of patients, levels T3 and T4 in 3% of patients, levels T2 to T4 in 14% of patients, and greater than three levels in 14% of patients. Significant CS, as defined in this study by an iQOL of 2 or more, was seen in 33% of patients overall and occurred in 29% of patients with palmar symptoms, 26% of patients with axillary symptoms, and 42% of facial blushers. To better delineate the relationship of extent of sympathicotomy to significant CS, we analyzed the incidence of significant CS with respect to the operation performed, or more specifically, the level(s) of sympathetic chain division (Table 1).
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Comment |
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In surgical centers with extensive experience with this procedure, there is a very low incidence of perioperative complications, and the operation can be carried out as a very straightforward procedure [1–5]. Although results with this operation have been excellent overall, especially with respect to the treatment of palmar symptoms, there is still debate among thoracic sympathetic surgeons regarding how best to modify the operation to better address differing patient symptomatology, and to decrease unwanted side effects such as CS.
Compensatory sweating is an unwanted but fairly common side effect of sympathetic nerve surgery and may negatively impact the quality of life of patients after the operation. Although rates of CS have been reported from as low as 30% to as high as 90% [4, 9–14], interestingly, the vast majority of patients still express high satisfaction with the results of this operation with respect to alleviation of their primary symptoms. Although we have found that our operative results compare favorably with other large reported series [1, 2, 9–14], we sought to better understand the relationship between the sympathicotomy performed and the true impact of CS in our patients. Therefore, we conducted an analysis of CS stratified to the precise level(s) of sympathicotomy performed at operation and found that significant CS appears to be indeed related to the level and extent of surgical treatment of the sympathetic nerve chain, which has previously been reported otherwise [15]. From our data, the highest rates of CS rates were found in those patients in whom a high T2 sympathicotomy plus lower stellate ramicotomy was performed for facial blushing and in patients receiving more than three levels of sympathicotomies. The lowest significant CS rate was found in surgeries involving T3 and T4 sympathicotomies, which is our preferred operation for patients with severe isolated axillary hyperhidrosis. Others have also found that T4 sympathicotomy is important in the treatment of axillary symptoms [7]. Our analysis of preoperation versus postoperation iQOLs stratified to preoperative symptoms (hyperhidrosis, facial blushing, or both) also corroborate that hyperhidrosis patients derive the greatest symptomatic improvement as a result of sympathicotomy surgery, a result similarly observed by others [1, 2, 5–7]. The facial blushing group appears to derive less substantial improvement in their quality of life from surgery, which may be a reflection of the relatively higher postoperative clinically significant CS rate among these patients.
Although from data such as these it may seem attractive to some to advocate this lower T3 and T4 sympathicotomy procedure for other hyperhidrosis patients as well (axillary, palmar, or combination), one should note the reported 3% incidence of lack of relief of palmar symptoms when treating with this lower level sympathicotomy [6]. Thus, it may be unlikely that any one operation (one-size-fits-all concept) can yield superior results for all the varying presentations of clinical hyperhidrosis (palmar, axillary, and palmar plus axillary) and facial blushing. However, future refinements of this procedure should take into consideration both the potential for clinically significant CS as well as the potential for loss of treatment efficacy. Any loss of efficacy in our current almost uniformly successful procedure for palmar hyperhidrosis, which represents the great majority of patients seen in practice, may be unacceptable to future patients no matter how small the failure rate.
Thoracoscopic sympathetic nerve clip application (also known as clamping) has recently been proposed by some as an alternative to thoracoscopic sympathicotomy or sympathectomy. Sympathetic nerve clamping has been described to involve placing multiple surgical clips above and below a targeted sympathetic level ganglion to interrupt the neural impulses traversing that segment of the nerve chain. Proponents of this operation hoped that this modification might alleviate hyperhidrosis and also decrease the incidence of CS; however, it appears from one recent report that the CS rate with surgical clamping can be as high as 84% [16]. Another argument made in favor of the surgical clamping procedure is its theoretical potential for reversibility of such an operation. From that standpoint, unfortunately, there have been only a mere handful of such reversals done with the surgical clamping technique and reported in the literature [16, 17]. Disappointingly, the reported reversals met with varied success. Thus, surgical clamping should be studied cautiously while further investigations are pending with respect to its ability to reduce CS, consistently produce reversal of symptoms when desired, and whether its long-term results will be as durable as those of sympathicotomy.
Although obvious factors for success in this operation include accurate identification of intrathoracic rib anatomy and the sympathetic chain, we advocate that careful patient selection and frank discussion with the patient in the preoperative setting regarding the potential limitations and possible side effects and complications, as well as the likelihood of success with this operation, are essential to an overall successful surgery.
We also support that general agreement and adoption of a uniform nomenclature in describing sympathetic nerve surgery will greatly serve to render more ease and clarity in understanding the implications of future clinical studies in this field and enhance the possibility to improve this operation for our patients. Unfortunately, a uniform language is currently lacking in the literature when describing these procedures. For example, one can find in one reference the description of a T2 sympathicotomy to mean that two separate cuts are made on the nerve chain (one cut above the T2 ganglion and a second cut made below it), whereas another report described this same procedure as T2 and T3 sympathicotomies, meaning cuts at both the T2 and T3 rib levels. Although both surgeons may be performing the same technical operation, inconsistencies in such descriptions and nomenclature lead to difficulties in interpreting and extrapolating clinical data from across the medical literature. A reasonable set of common definitions regarding sympathetic nerve surgery is therefore proposed in Table 2.
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Discussion |
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DR KWONG: Upon entering the chest, it is important to first get a general global look. We always do a limited diagnostic thoracoscopy to make sure that there are not any significant findings, such as unexpected intrathoracic masses, azygous lobe, adhesions, and so forth. But in terms of landmarks for identifying the sympathetic chain, the sympathetic chain usually overlies the rib heads as they articulate with the spine. However, this can have some variations, and there is a small subset, about 20% of patients, who will have a bifid chain, where you could divide what you presume to be the main chain, but then there would be another component parallel to it. The chain as it is illustrated in the textbooks and anatomy descriptions or illustrations makes it seem very consistent, but there is quite a lot of meandering, especially with the more cephalad aspects of the chain. The key landmarks include identifying the fat pad that overlies the stellate ganglion superiorly and identifying the rib levels. It is also important to use visual as well as tactile feedback when counting rib levels. So we actually use a probe to palpate the first rib and so on. Obviously, we do not disturb the stellate ganglion. Once you identify the ribs, you can then count the ribs and go down from there to identify your second level, third level, and so forth. Those are some of the key aspects to making sure you are in the right place.
DR JOSE RIBAS MILANEZ DE CAMPOS (Sao Paulo, Brazil): Congratulations for your paper and for the nice presentation.
I am very happy to see that this paper is confirming that the levels are very important for good results in thoracic sympathectomy, especially to reinforce that we must avoid operating at the level of T2 for palmar or axillary symptoms.
I would like to add a comment about a limited sympathectomy. A limited sympathectomy (just one level), could also be effective and with less incidence of compensatory sweating. My question for you is, with these results, are you thinking of changing your indication in the levels that you actually do or not?
DR KWONG: Thank you for your comments, Doctor De Campos. Your significant work in this field is well known, and we have read your papers with extreme interest. Looking at our data, we feel that we have had some very consistent and robust clinical results, especially among our patients with palmar hyperhidrosis. In fact, we have not had any treatment failures in that group. In reading the medical literature, many other surgeons also do what is effectively a T2 and T3 sympathicotomy to treat this patient group. So obviously the issue is not settled as far as which are the best levels. In reviewing the literature and experience of others, not unexpectedly, there are some caveats, though, before we go ahead and change something that we have been doing for a good number of years with practically uniform success. Although it is desirable to lower the significant compensatory sweating rate by moving to a lower level, we must consider possibly sacrificing the high level of success already seen in palmar hyperhidrosis. In one recently published series from Brazil, by treating lower levels on the sympathetic chain, there was at least one treatment failure out of 30 patients; whereas reported in that same paper, the same investigators doing the higher levels did not have any treatment failures. Granted, that study had only 30 patients in each arm. Nonetheless, the worrisome issue is having more treatment failures with the lower levels. Since the primary reason why these patients are getting the surgery is palmar hyperhidrosis, it is unclear whether a lower rate of success will be acceptable to them. So to answer your question, at this moment, I do not think we are changing what we are doing quite yet, but as we see more data, we need to continually reevaluate how we can better this operation. Thank you.
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This article has been cited by other articles:
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  T. Walles, G. Somuncuoglu, V. Steger, S. Veit, and G. Friedel Long-term efficiency of endoscopic thoracic sympathicotomy: survey 10 years after surgery Interactive CardioVascular and Thoracic Surgery, January 1, 2009; 8(1): 54 - 57. [Abstract] [Full Text] [PDF]
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