| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Section of General Thoracic Surgery, Department of General Surgery, Emory University School of Medicine, Atlanta, Georgia
Accepted for publication November 6, 2007.
* Address correspondence to Dr Miller, Section of General Thoracic Surgery, Emory University Clinic, 1365 Clifton RD NE, Atlanta, GA 30322 (Email: daniel.miller{at}emoryhealthcare.org).
Presented at the Fifty-third Annual Meeting of the Southern Thoracic Surgical Association, Tucson, AZ, Nov 8–11, 2006.
 |
Abstract |
|---|
 Top Abstract IntroductionMaterial and MethodsResultsCommentDiscussionReferences |
|---|
Methods: We reviewed all patients who underwent a temporary thoracoscopic sympathetic block and subsequent thoracoscopic sympathectomy for medical refractory PH. All patients were concerned about the development of CH and requested the possibility of a reversible procedure.
Results: Twenty-five patients underwent a temporary thoracoscopic sympathetic block; 18 suffered from palmar, axillary, and plantar hyperhidrosis, 4 had axillary and plantar hyperhidrosis; and 3 had palmar and plantar hyperhidrosis. The sympathetic block and subsequent sympathectomy were performed as outpatient bilateral thoracoscopic procedures. Sympathetic blockade was performed at each level of the planned sympathectomy (T2, T3, and accessory nerves) with 2.5 cc 0.25% marcaine with epinephrine per level without complications. All patients had temporary relief of hyperhidrosis ranging from 1 to 10 days with a median of 4 days after the block. Three patients (12%) had temporary CH after the thoracoscopic block, 2 mild and 1 severe. All but 1 (4%), the severe CH patient, elected to proceed with the planned sympathectomy; all sympathectomy patients (100%) were cured of their excessive sweating. The 2 patients who experienced mild CH after the thoracoscopic block also had it after the sympathectomy. All patients were completely satisfied with the final results, even the 2 patients in whom mild CH developed.
Conclusions: Temporary thoracoscopic sympathetic block is a reversible and accurate procedure for the determination of postsympathectomy CH. A temporary thoracoscopic sympathetic block followed by sympathectomy may be the best approach for the treatment of medically refractory PH in patients who are concerned about the development of postsympathectomy CH.
|
Introduction |
|---|
|
TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionReferences |
|---|
Compensatory hyperhidrosis is generally believed to be a reactive thermoregulatory mechanism. The extent of the sympathectomy and primary indication is believed to influence the severity and frequency of the CH [4–6]. A standard sympathectomy is a permanent procedure. Several authors have suggested clipping the chain as a potentially reversible procedure so that, if needed, removal of the clips could be performed to reverse the CH [7–9]. Unfortunately, clip removal has not been as reversible as once initially thought for CH [7–10]. We developed a technique of a temporary thoracoscopic sympathetic block to determine if postsympathectomy CH could be predicted and thus prevented. This study is of our early experience in patients who underwent a temporary thoracoscopic sympathetic block and subsequent thoracoscopic sympathectomy for medically refractory primary hyperhidrosis (PH) because they were concerned about the development of permanent postsympathectomy CH.
|
Material and Methods |
|---|
|
TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionReferences |
|---|
Clinical Findings
There were 20 women (80%) and 5 men; median age was 18 years (range, 14 to 38). Primary palmar, axillary, and plantar hyperhidrosis was the primary indication in 18 patients, palmar and plantar in 3 patients, and axillary only in 4. Medical treatment was exhausted before patients were considered for sympathectomy. Previous medical treatment consisted of topical agents, most commonly aluminum chloride in 25 patients (100%), oral medications (robinul, probathine, or β-blockers) in 24 (96%), iontophoresis in 4 (16%), botulinum toxin injections in 3 (12%), and other treatments in 8 (32%). Median period of medical treatment before the block was 102 months (range, 48 to 280).
Surgical Technique
The first procedure, temporary VATS sympathetic block, is performed as an outpatient procedure within our hospital’s main operating room or in our ambulatory surgical center. The patients are placed in a supine position. General anesthesia is initiated with a single-lumen endotracheal tube, usually 7.0F or 7.5F. After the patient is asleep, the arms are extended laterally to 90 degrees. Excessive abduction of the upper extremities is avoided to prevent injury to the brachial plexus. Temperature probes are placed on each index finger. Each axilla is prepared in standard fashion. Attention is first directed to the right side. A single 4-mm incision is made vertically over the fourth rib along the midaxillary line. Using a mosquito clamp, the chest cavity is entered over the fourth rib during suspension of ventilation. During continued ventilation suspension, a 3-mm, 30-degree rigid thoracoscope (Karl Storz, Munich, Germany) is placed. Alongside the thoracoscope a standard laparoscopic Varess needle (Ethicon, Cincinnati, Ohio) is also placed. After the two instruments are placed without difficulty, ventilation is resumed with a decrease tidal volume of 250 cc for women and 300 cc for men. Temporary CO2 insufflation is carried out to 10 mm HG for approximately 30 s to 90 s to allow partial collapse of the lung. A detailed examination is carried out of the apical and posterior chest to accurately identify the anatomy of the sympathetic chain and its accessory nerves. Before performing the block, a finger temperature is recorded as a baseline measurement.
The block is performed by placing a 2-mm hollow semirigid catheter alongside the thoracoscope to the apex of the chest under direct visualization. A 22G laparoscope is then placed through the catheter. The sympathetic chain is injected with 2.5 cc 0.25% marcaine with epinephrine at each planned sympathectomy site and 1.0 cc at each accessory nerve. After completion of the block of the primary nerve and its accessories, a postblock temperature is taken at 5 minutes. The needle is removed and external end of the catheter is placed in a basin of sterile water to create a water seal. Utilizing sterile water immersion of the catheter, positive pressure ventilation to 40 mm Hg, and suctioning the pneumothorax is evacuated. After the pneumothorax is evacuated, the catheter is removed. The skin is reapproximated with a dermal bonding adhesive. The left side is completed in similar fashion. Then 15 cc 0.25% marcaine is injected into each incision before making the incision and at the time of closure. Also, 30 mg ketorolac is given intravenously before making the incision. The patient is taken to the recovery room for an upright chest radiograph and subsequent planned dismissal.
The subsequent sympathectomy is usually performed within 4 weeks of the VATS block procedure. Again, the procedure is performed as an outpatient within our hospital’s main operating room or in our ambulatory surgical center. Redo single 4-mm bilateral incisions are made incorporating the previous incisions. Again using a mosquito clamp, the chest cavity is entered over the fourth rib during suspension of ventilation. During continued ventilation suspension, the thoracoscope and Varess needle is placed. After the two instruments are placed without difficulty, ventilation is resumed. Temporary CO2 insufflation is carried out. The Varess needle is removed and through the same incision alongside the thoracoscope, a 2-mm long electrocautery is placed. Again, a detailed examination is carried out of the apical and posterior chest to accurately identify the anatomy of the sympathetic chain and its accessory nerves. Before the sympathectomy, a finger temperature is taken for a baseline measurement. The sympathetic chain is then divided over the second, third, or fourth rib to complete the planned T2 only, T2 to T3, or T3 to T4 sympathectomy, respectively, with a 2-mm long electrocautery. All accessory nerves are also divided with electrocautery. The cauterized ends of the nerves are separated from each other to allow at least a 1.0 to 1.5 cm gap to diminish the chance of regrowth and possible recurrence of PH. The external end of the catheter is placed in a basin of sterile water to create a water seal, and the pneumothorax is evacuated as described above. After the pneumothorax is evacuated, the catheter is removed. The skin is reapproximated with a dermal bonding adhesive. The left side is completed in similar fashion. Then, 15 cc 0.25% marcaine is injected into each incision before making the incision and at the time of closure. Also, 30 mg of ketorolac is given intravenously before making the incision. The patient is taken to the recovery room.
In the recovery room, an upright chest radiograph is obtained approximately 30 minutes after completion of the procedure. If the chest radiograph is satisfactory and the patient is having minimal discomfort, the patient is allowed to be discharged. The patients are asked to return to the clinic within 3 to 4 weeks after their procedures for follow-up.
|
Results |
|---|
|
TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionReferences |
|---|
Follow-up was complete in all 25 patients and ranged from 6 to 24 months (median, 12). Compensatory hyperhidrosis developed in 3 patients (12%) after the thoracoscopic sympathetic block, 2 cases were mild and 1 was severe. All but the 1 severe CH patient (4%) elected to proceed with the planned sympathectomy. The 2 patients who experienced mild CH after the thoracoscopic block also experienced it after the sympathectomy. The CH was mild and required no treatment. All patients (100%) were completely dry in their treated areas and were satisfied with the procedure, even the 2 patients with mild CH.
|
Comment |
|---|
|
TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionReferences |
|---|
The mechanism of CH is related to thermoregulatory function of the remaining sweat glands for temperature regulation after the decrease of the function of a large number of sweat glands [5]. Treatment of CH is usually unsatisfactory. A small number of patients may respond to anticholinergic agent (Robinul) for CH, but the benefits are usually short lived. Teralanta [14] claims that CH could be treated by reconstructive surgery of the sympathetic trunk using the sural nerve. The results of this procedure are in question.
The best why to prevent CH is not to cause it. It very important to maximize the conservative treatment before sympathectomy. There are a number of patients who will not need a sympathectomy because of successful medical treatment. However, the majority of these treatments are cumbersome, expensive, and painful. Also, after a period of time, a significant number of these treatment modalities become less effective because medical tolerance develops.
One potential way to determine if CH may be a problem postoperatively is to first do a temporary block of the nerve. Currently, there is no accurate percutaneous sympathetic block technique available. Computed tomography–guided blocks may be performed, but anatomical accuracy is poor and treatment of accessory nerves, if present, is not possible. Currently, the only method of performing a so called "temporary" or "reversible" sympathectomy is to place clips on the nerve at the time of sympathectomy. Several authors have recommended this procedure because if a patient develops intolerable CH after the sympathectomy, the clips could be removed during a second procedure, thus reversing the CH [15–17]. We have operated on several patients who have had clips placed elsewhere. We were successful in removing the clips without transecting the nerve, but none of the patients had their CH corrected. The multiple clips more than likely caused permanent damage to the nerve that would not allow regrowth or acceptable signaling along its path. Several series have reported success of reversing CH with clip removal, but the success has varied from 15% to 100% [7–9, 15–17]. One of the main problems with clip placement is that a significant number of patients do not achieve the same success with relief of their primary hyperhidrosis as compared with sympathectomy [7–10, 15, 16]. This is further confirmed in that the majority of clipping procedures are carried out utilizing several clips (3 to 5) to completely disrupt the signal impulse through the nerve [16].
Because of the disappointment of reversible sympathectic nerve clipping, we decided to perform a temporary thoracoscopic block of the nerve with a local anesthetic such as marcaine. The theory is that if you can mimic the sympathectomy temporarily (less than 7 days) with an anesthetic agent long enough so the patient can determine if CH is going to be problematic, then it would serve as a predictive procedure for the development of CH postsympathectomy. The injection block sites would be at the planned sympathectomy levels and also all of accessory nerves to prevent recurrences, but the effect of the block would be temporary. If patients experience good results from the block with complete dryness and no CH, then they could return for a sympathectomy. However, if a patient develops significant CH, which would be temporary, lasting usually less than a week, the patient would have avoided permanent CH and more than likely not proceed with a sympathectomy, as occurred in 1 of our patients. If block CH is mild, the patient may still elect to proceed to sympathectomy. In our series, 3 patients had postblock CH, 2 cases were mild and 1 was severe, all within 5 days of the block. The 1 patient who had the severe CH avoided a permanent undesirable situation that was worse than her PH.
Performing a repeat VATS procedure did not lead to any problems. There were no complications at the time of the second procedure related to lung parenchymal injury, bleeding, postoperative air leak, or pneumothorax. No patient required a chest tube. At the time of the second procedure, there were no adhesions at the block site to prevent sympathectomy, and the subpleural sympathetic chain and its accessory nerves were easily identified. The reason for the ease of a second procedure is multifactorial: minimal pleural injury, single microaccess incisions, and an early median reoperation time of 20 days that prevented the development of any significant pleural adhesions. Also, both procedures were reimbursed without issue because of the detailed documentation of treatment failures and overall success of both procedures. There was no difference in postoperative pain or recovery after the two procedures than after our usual single procedure. These 25 temporary block patients represent only 2.9% of our total experience of 850 sympathectomy patients.
Patients who have primary palmar hyperhidrosis seem to have the lowest risk of CH, whereas patients who have hyperhidrosis affecting not only the palms, but also the axillary are at an increased risk of developing CH [11–13, 18]. In this series, the majority of patients had an axillary component as their indication for surgery, thus increasing their risk of developing CH. Three patients, however, only had palmar and plantar hyperhidrosis and underwent single T2 procedures. All 3 patients were long-distance runners and were concerned about the effects of sympathectomy on their ability to generate sufficient heart rates during their running. All 3 were able to run significant distances while the effect of the block was still working, to test if the chronologic cardiac effect was impaired because of sympathetic denervation. That also helped prove that this microinvasive temporary VATS block is a well-tolerated minimally invasive procedure.
In closing, hyperhidrosis can be psychologically debilitating, but CH is even more of a challenge because of its irreversibility. Early results suggest that a temporary thoracoscopic sympathetic block is a reversible and potentially accurate predictive procedure for the determination of postsympathectomy CH. Temporary thoracoscopic sympathetic block followed by sympathectomy may be the best approach for the treatment of medically refractory PH in patients who are concerned about the development of CH. A multicenter prospective trial is warranted to confirm the validity of this new diagnostic procedure.
|
Discussion |
|---|
|
TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionReferences |
|---|
In this series by Dr Miller, we hear of another novel approach to minimize compensatory sweating, the so-called quagmire operation. This remains the only significant complication and the main cause for dissatisfaction and even lawsuits in this area. The idea of sympathetic nerve block is appealing. In fact, our group has used this as a preoperative assessment of patients undergoing sympathectomy for reflex sympathetic dystrophy, since the success rate in this subgroup is much worse. This idea, first suggested to me by Hal Urschel, has been used also as an evaluation tool for patients with digital ischemia undergoing sympathectomy.
Although very appealing, I have one major concern that I wish to mention immediately with this series. Although the Institutional Review Board approved a retrospective review of this data, I would caution that the prospective performance of a thoracoscopic nerve block should have involved an IRB consent as an experimental procedure. I would strongly encourage you, Dr Miller, to do this every time you develop new operations.
I have three questions. How long after the procedure was the questionnaire performed, and did it include a numeric scoring system for quality of life such as that described by Dr Kwong, Dr De Campos, and others? Number two, your technical description in the paper was excellent. Have you tried a single incision with a small pediatric Storz scope, which measures only 7 mm in size and allows the cautery probe to go through the center? Also, have you considered using a percutaneous, perhaps fluoroguided technique for your nerve block and then do the sympathectomy? And finally, how did you bill for the two procedures? Was there a problem with the second procedure coming less than 30 days in most of these cases?
I congratulate you on attempting to sort out this vexing problem. Seriously, I think that longer follow-up will be needed, including seeing each of these patients at least through one summer season, but then I think we can determine whether this operation truly has a less than 7% compensatory sweating rate. I thank the Association for the privilege of discussing this paper.
DR MILLER: Thank you, Dr Krasna, for your comments. I yield to your expertise in this area. You have presented several excellent papers at the Southern on hyperhidrosis. From those papers and both of us moderating together at the STSU course on hyperhidrosis, I have modified my VATS procedure for medical refractory hyperhidrosis.
In regard to your questions, a fluoroscopic sympathetic block can be performed before sympathectomy, but it is not as accurate as the VATS block. When we are doing the VATS block, we can accurately identify and block the sympathetic level for the later planned sympathectomy, and the accessory nerves can also be addressed at the same time.
In regard to your question about a single incision and a small 7-mm scope, we currently use a 3-mm, 30-degree scope and place 2-mm instruments alongside the scope through the same incision. We also do only one incision on each side, which usually measures 4 to 5 mm in size.
In regard to the IRB, I do not agree with you that an IRB approval is necessary to perform a VATS sympathetic block. Percutaneous sympathetic (stellate) blocks are performed by our pain service routinely. We had a discussion with our pain service before proceeding with the VATS block, and they did not feel there was an issue because it is an established procedure in the operating room, and we are performing the same procedure just by a different approach. It would be the same in regard to VATS lobectomy; none of us got IRB approval that I know of for VATS lobectomy because it was just a different approach for a routine procedure.
In regard to the billing, these are the codes (slide shown) that we use for the bilateral sympathectomy, where as for the sympathetic block we use 64520. We have had no problems with reimbursement for either procedure, even when they are both completed within 30 days.
And lastly, in regard to the questionnaire, the majority of the patients did not come back to the office before their sympathectomy. The questionnaire was completed by telephone after the block when the patient was deciding the date of their sympathectomy. We did not use the Brazilian scale for quality of life. Thank you.
DR EMMANUEL DAON (Kansas City, MO): Doctor Miller, that was a very nice presentation. I wondered if it is truly worth putting patients through two different general anesthetics for the same problem. Also, there are at least some reports in the literature that one of the ways to combat compensatory sweating is to perform a single-level sympathectomy as opposed to multilevel, and I wonder if you could comment on that, please.
DR MILLER: The main issue is that you are putting a patient through two procedures, but you are doing the same thing when you place removable multiple clips. When you remove the clips for postoperative compensatory hyperhidrosis, you are putting the patient through two procedures because the first is a reversible of the procedure just like the VATS block. The VATS block appears to much more reliable then the clip sympathectomy. A small percentage of our patients were interested in the block procedure. During this time period, 152 patients underwent a sympathectomy at our institution, so only 10% of patients underwent a temporary block.
We reported last year at this meeting that a single-level sympathectomy had a compensatory sweating rate of 12%, which is extremely low. One of the patients in that series has regretted to this day that she underwent a permanent procedure, because she has to change her clothes two or three times a day because of severe compensatory hyperhidrosis.
In this series, the majority of the patients had an axillary component, because it has been shown that the further you go caudally on the chain and do multiple levels, the incidence of compensatory hyperhidrosis increases. The 2 patients in our series who had palmar hyperhidrosis were both collegiate athletes who had track scholarships, were concerned about their cardiac response when they would run. So that is the reason we did a temporary block on them. Two days after the block, one of them ran 10 miles, had no problems, so that is why we had the palmar patients. Thank you for a very good question.
DR BRYAN FITCH MEYERS (St. Louis, MO): What you are proposing is basically a screening operation, but the importance of a screening test or a screening procedure is to segregate patients into high risk and low risk, and from your results I didn’t really see that there was much segregating that took place. If a careful operation results in about a 30% or 40% risk of compensatory sweating, then I would hope that a screening test like the one proposed would have a 30% or 40% positive rate, and then you could say that the results of the screen would mimic or predict the results of the operation. However, your screen didn’t really identify people with problems. So, I wonder how you grapple with that?
DR MILLER: In a series that we presented at the Western Thoracic earlier this year, we looked at what factors were associated with a higher risk of compensatory sweating. Three factors were identified that were associated with compensatory hyperhidrosis: multiple level sympathectomy, higher body mass index, and age greater than 30. So I think, Bryan, working with you and our statistical colleagues, we could screen the patients better. We see a large number of patients for sympathectomy, but operate on the minority. We exhaust all medical therapy and have them see our dermatologists. I wish we had a better way to screen these patients, because when you do a sympathectomy and they develop compensatory sweating, it can be a permanent disabling problem that can be worse than the primary sweating. A VATS block may be the procedure of choice to predict compensatory hyperhidrosis.
|
References |
|---|
|
TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  R. J. Cerfolio, J. R. M. De Campos, A. S. Bryant, C. P. Connery, D. L. Miller, M. M. DeCamp, R. J. McKenna, and M. J. Krasna The Society of Thoracic Surgeons Expert Consensus for the Surgical Treatment of Hyperhidrosis Ann. Thorac. Surg., May 1, 2011; 91(5): 1642 - 1648. [Abstract] [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 |
