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Department of Thoracic Surgery, St. Lukes-Roosevelt Hospital Center, 1000 Tenth Ave, Suite 2B07, New York, NY 10019
(Email: cconnery{at}chpnet.org).
Thoracic sympathectomy is an appropriate treatment for properly selected patients with hyperhidrosis who have undergone failed conservative measures.
In general the results and satisfaction after video-assisted thoracic sympathectomy are excellent for patients with palmar or palmar and axillary symptoms combined, but there is a subset who will be dissatisfied mainly due to severe compensatory sweating. Other reasons for dissatisfaction outside of complications would be inadequate control of symptoms or symptom recurrence.
Despite the extreme variations in description of results and the multitude of different surgical techniques, there is a growing impression that limiting the number of sympathetic levels interrupted and avoiding, if possible, the interruption of the T2 ganglion may help reduce the incidence of severe compensatory sweating [1].
The problem is that previously reported attempts to minimize the surgical approach have been associated with an increased incidence of recurrence or inadequate control of symptoms [2]. There is a stunning variation in reported results in the literature; part of this may be due to variability in the sympathetic chain, but clearly a large portion of this discordance is due to nonstandard descriptions of anatomy, techniques, and results.
In this manuscript Li and colleagues [3] have postulated that a patient's surgery could be individualized to recognize possible anatomic variation by using intraoperative testing.
Their use of skin temperature and Doppler blood flow changes to gauge adequacy of response, although somewhat arbitrary, is a commendable effort to try to use some "science" when making treatment decisions.
By limiting the extent of sympathectomy, their goal was to minimize the risk for severe compensatory sweating, but still interrupt the sympathetic chain sufficiently to achieve an adequate clinical response. The goal of procedural efficacy for palmar symptoms seems to have been achieved at 1 year, but there still was an 8% dissatisfaction rate. Their reported data does not clearly define the reasons for this nor does it identify by extent of surgery the severe compensatory sweating that developed in 6% of patients.
It is imperative that clinicians treating patients with hyperhidrosis come to an understanding as to descriptions of disease severity, treatment response, surgical techniques, and follow-up so that we can use the experience of a number of investigators to better understand how to advise and treat patients with severe hyperhidrosis. Organizations such as our thoracic societies and the International Society of Sympathetic Surgery (ISSS) can help encourage these efforts.
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