Ann Thorac Surg 2009;88:1780-1785. doi:10.1016/j.athoracsur.2009.08.007
© 2009 The Society of Thoracic Surgeons
Original Articles: General Thoracic
T3T4 Endoscopic Sympathetic Blockade Versus T3T4 Video Thoracoscopic Sympathectomy in the Treatment of Axillary Hyperhidrosis
Marlos de Souza Coelho, MD, PhD*,
Ruy Fernando Kuenzer Caetano Silva, MD,
Giovanni Mezzalira, MD,
Nelson Bergonse Neto, MD,
Wilson de Souza Stori, Jr, MD,
Anna Flávia Ribeiro dos Santos, MD,
Samir El Haje, MD
Thoracic Surgical Department, Hospital Universitário Cajuru, Curitiba, Brazil
Accepted for publication August 6, 2009.
* Address correspondence to Dr de Souza Coelho, Rua Dep. Leoberto Leal, 187Guabirotuba, Curitiba, Paraná,81 510 090, Brazil (Email: clinicadotorax{at}marloscoelho.com.br).
Presented at the Poster Session of the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.
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Abstract
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Background: The use of endoscopic sympathetic blockade (ESB) in the treatment of axillary hyperhidrosis has grown because of its potential reversibility. But it is still not clear whether the rates of success, compensatory sweating, and satisfaction are better than those accomplished with video thoracoscopic sympathectomy (VTS).
Methods: Eighty-four patients were studied to compare the rates of success, satisfaction, and compensatory sweating in patients undergoing either ESB or VTS of the T3T4 ganglion after 2 years' follow-up.
Results: Thirty-five patients (83.3%) undergoing ESB and 39 patients (92.8%) undergoing VTS had remission of axillary hyperhidrosis (p = 0.315). Improvement was seen in 7 patients (16.7%) in the ESB group and 1 patient (2.4%) in the VTS group. Two patients (4.8%) had bad results in the VTS group. Absence of or minor compensatory sweating was observed in 25 patients (59.5%) in the ESB group and 28 patients (66.7%) in the VTS group, and moderate compensatory sweating occurred in 13 patients (31.0%) in the ESB group and 10 patients (23.8%) in the VTS group. Severe compensatory sweating was observed in 4 patients (9.5%) in the ESB group versus 4 patients (9.5%) in the VTS group (p = 0.905). In the ESB group, 28 patients (66.7%) were very satisfied, 11 patients (26.2%) were satisfied, and 3 patients (7.1%) were unsatisfied with treatment. In the VTS group, 35 patients (83.3%) were very satisfied, 6 patients (14.3%) were satisfied, and 1 patient (2.4%) was unsatisfied with VTS.
Conclusions: Endoscopic sympathetic blockade and VTS of T3T4 ganglion are efficient in axillary hyperhidrosis treatment. We found no differences regarding therapeutic success, satisfaction rate, and incidence, severity, and location of compensatory sweating.
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Introduction
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Primary hyperhidrosis is characterized by autonomic sympathetic nervous system hyperactivity, and presents as excessive sweating in the affected region. Primary hyperhidrosis is usually intermittent and influenced by emotional factors, such as anxiety or fear, and by stimulating drugs, such as caffeine and caffeinelike substances present in coffee, tea, and cola soft drinks [1].
Axillary hyperhidrosis (AH) is a form of primary hyperhidrosis, defined as excessive sweating in the axillary region that exceeds physiologic needs, especially in response to environmental heat and emotional stimuli. Axillary hyperhidrosis, especially when associated with bromidrosis (foul-smelling sweating), interferes in personal, familiar, and social activities, resulting in negative psychological reactions [2].
Many studies have been published on the treatment of primary hyperhidrosis, but very few have addressed specifically the treatment of AH, associated or not with bromidrosis. Axillary hyperhidrosis is often treated successfully by topical use of 20% to 24% aluminum chloride in alcohol. The clinical experience with botulinum toxin has grown recently, and some authors now regard it as the treatment of choice for AH [3, 4]. Other surgical methods, such as resection of sweat gland–bearing skin and sweat gland curettage, have been met with good results [4, 5].
Video thoracoscopic sympathectomy (VTS) has been used for the treatment of AH with good immediate results and has been indicated after failure of medical treatment [3, 6]. Few studies, however, have reported on the long-term results of VTS. Its side effects, especially compensatory sweating (CS), are well known [7], which is the main reason for dissatisfaction with the surgery. Endoscopic sympathetic block (ESB) has been successfully used in the treatment of AH. Because of potential reversibility, ESB brought a new dynamic to the treatment of the condition [2]. The aim of this prospective study was to investigate the rates of success, CS, and satisfaction after 2 years' follow-up in patients undergoing ESB and VTS in the treatment of AH.
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Patients and Methods
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Eighty-four patients with AH underwent video-assisted thoracic surgery. Fifty-one patients (60.7%) had associated palmar or plantar hyperhidrosis, or both (Table 1). This was a prospective study to compare the rates of success, satisfaction, and CS after 2 years' follow-up in patients undergoing either ESB or VTS of the T3T4 ganglion in the treatment of AH in the Department of Thoracic Surgery, Hospital Universitario Cajuru e Santa Casa de Misericordia de Curitiba from Pontificial Catholic University of Parana. A total of 84 patients were included in the study; the last 42 enrolled patients underwent VTS and the first 42 enrolled patients underwent ESB. All patients were referred by a dermatologist and had undergone prior nonsurgical treatment. The patients underwent treatment according to an institution-approved protocol and in accordance with the ethical standards of the Ethics Committee for Analysis of Research Projects on Human Experimentation. All patients provided written informed consent before being admitted for surgery.
All patients were healthy, with nothing notable in their history or on physical examination; demographics data are presented in Table 2. Preoperative work consisted of complete blood cell count, coagulation panel, electrocardiogram, and chest roentgenogram.
All patients underwent the procedure under general anesthesia with a single-lumen endotracheal tube and controlled apnea. The patient was placed in a supine position with the trunk elevated 45 degrees, and the upper limbs abducted 90 degrees. A 5-mm incision was made in the fourth intercostal space at the anterior axillary line, to introduce the 30-degree rigid endoscope. The second incision was a midaxillary incision for the surgical instruments, in the third or fourth intercostal space. Under endoscopic view, an incision was made in the parietal pleura, beside the thoracic sympathetic chain.
The patients were divided into two groups according to the surgical technique used: ESB when the sympathetic chain was dissected and titanium clips used, and VTS when the ganglion was thermally ablated. Video thoracoscopic sympathectomy was performed by electrocoagulating the sympathetic trunk and ganglion between the third and fifth ribs by thermal electrocautery, thus destroying the T3 and T4 ganglia. Endoscopic sympathetic blockade was performed after careful dissection of the sympathetic chain over the third, fourth, and fifth ribs to avoid damage to the periosteum using two 5-mm titanium clips and a nondisposable clip applier from EDLO-EXATECH (EDLO Company, Canoas, Brazil) on the sympathetic trunk over the third, fourth and fifth ribs. At the end of the procedure, 10 mL of 0.5% bupivacaine was injected into the pleural space, and a thin chest tube was left under water seal. The lung was inflated under direct visualization, and the thoracic drain was removed immediately after lung reexpansion. This procedure was repeated on the other side. The patients remained in the recovery room until fully awake and cooperative, and were discharged in the first postoperative day.
All patients underwent evaluations for the purpose of this study on the seventh and thirtieth days and at 6 months, 1 year, and 2 years after the operation, by personal visit. Therapeutic success was defined as "success" on the elimination or decrease of sweating in the affected area and was classified as "remission" when hyperhidrosis was eliminated or sweating remained mild in the patient, "improved" when partial relief of excessive sweating was experienced, and "poor" when excessive sweating persisted or had a slight improvement. Patient satisfaction was classified as "very satisfied," "satisfied," and "not satisfied," as reported by the patients themselves. Compensatory sweating is the sweating in another area different from that for which the patient was operated on and was classified as "mild" (little sweating at physical exercise, stress, or high environmental temperature); "moderate" (more intense sweating under the same conditions, occasionally causing embarrassing situations), and "severe" (profuse sweating causing embarrassment, even at rest at moderate environmental heat, and the patients reported interference in their social and professional activities that required changes of clothing). Patients who did not notice any difference in the location of their body sweating were considered to be unaffected by compensatory hyperhidrosis.
The data were analyzed using the parametrical Student's t test and nonparametrical tests for comparison between two proportions, 
2, and Fisher's exact test. We adopted a level of statistical significance when less than 5% (p < 0.05).
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Results
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No statistical differences of the therapeutic success rate were observed at the end of 2 years' follow-up between the ESB and VTS groups. In the VTS group, 2 patients (4.8%) had recurrence of the AH. One relapse was detected during the first year and another in the second year after operation. Both underwent VTS of the T5 ganglia, which has been successful in 1 patient (Table 3).
Compensatory sweating was observed in 65 patients (77.4%) overall. There was no difference between the two groups regarding the presence, location, and degree of involvement of CS. The thorax and abdomen were the places most affected by CS (Table 4).
There was no statistical difference in relation to the evolution of the prevalence and degree of CS. In the VTS group, the prevalence of severe CS increased from 2 patients (4.8%) in the immediate postoperative period to 3 patients (7.1%) after 2 years. In the ESB group, CS increased from 2 patients (4.8%) to 5 patients (11.9%) at the same times (Fig 1).
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Fig 1. Evolution of compensatory sweating after operation. (ESB = endoscopic sympathetic blockade; VTS = video thoracoscopic sympathectomy.)
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At the end of 2 years of follow-up, 75.0% of patients were very satisfied, 21.4% were satisfied, and 4.8% were dissatisfied. No statistical differences were found between ESB and VTS (Table 5).
Compensatory sweating was the single reason given for dissatisfaction in 3 patients (3.4%) in the ESB group, but the patients did not want the clip removed. Poor therapeutic result was the reason given for the patient's dissatisfaction in 1 case (2.4%) in the VTS group.
Twenty-two patients (8.9%) had associated bromidrosis: 10 patients in the VTS and 12 patients in the ESB groups, respectively. In the VTS group 8 patients (80%) had their bromidrosis completely relieved and 2 patients (20.0%) had partial relief. In the ESB group, 10 patients (83.3%) had complete relief, 1 patient (8.3%) had partial relief. and 1 patient (8.3%) had failure. Pneumothorax was observed in only 1 patient (1.5%) in the VTS group.
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Comment
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Primary hyperhidrosis is a common disease occurring in 1% to 2.8% of the population [8], and the number of patients with AH who require surgery is similar to that of those with palmar hyperhidrosis. Patients with AH have their social, family, and personal life affected by the permanent sensation of sweating in the axillary region, even at low environmental temperatures. The wet spots on their clothing make them insecure of other people's opinion about their personal hygiene. Bromidrosis only exacerbates their insecurity. In the present study, there was a predominance of female patients, a finding confirmed by other authors [9]. The family history of hyperhidrosis ranged from 15% to 50% [10–12], and it was found in 31.1% of patients in this study, suggesting a hereditary factor.
The initial results of sympathectomy for AH treatment were not good enough (68% to 89%) [3, 10], and for this reason, some surgeons do not elect to treat isolated AH. Sympathicotomy or clipping at the T2 level for AH treatment has a low percentage of success [1]. Adding T3 transection improved the results, but not enough [12, 13]. Therapeutic success from 95% to 100% has been achieved with T2, T3, and T4 sympathectomy [14]. The addition of the T5 ganglion did not increase the efficacy of the operation [10]. It has been shown that ESB at the T3T4 levels has more effectiveness (86%), that T3 has a lesser role than T4, and that T4 is the most important level in the treatment of AH [3, 15]. Excellent outcomes have been reported in all patients with ESB at T4 for palmar hyperhidrosis and AH and without compensatory hyperhidrosis, but the results were evaluated too early [16].
Comparing T2T3T4 sympathicotomy with ESB by clamping of T4, success rates of 98.8% and 100%, respectively, were reported [16–18]. However, mild residual sweating rates of 9.9% and 35.5%, respectively, were observed. Regarding the sympathectomy of T4 and T3T4, in two studies all patients were cured of AH and did not report any recurrence, most likely attributable to a short follow-up. The patient satisfaction rates were similar, and the incidence and severity of compensatory hyperhidrosis was lower in the T4 group [19, 20]. Video thoracoscopic sympathectomy of T4T5 was better than VTS for T3T4, suggesting that T3 has a less relevant role in AH and that T4 is the most important element in the treatment of AH [21]. Clarification is needed regarding the treatment of AH in relation to the level to be subjected to clipping or ablation, but in this study, we demonstrated the effectiveness and degree of satisfaction at the T3T4 level.
Surgical failure could be recognized immediately, hours after the operation, particularly when there was difficulty performing the sympathectomy for anatomic or technical reasons [16]. Recurrence can happen in a few months after the operation, usually within the first year, but it can be mild, presenting only with warm weather or exercise. In such cases, reoperation is not indicated; however, in cases of full recurrence of symptoms reoperation is indicated. In the present study, there was no surgical failure, but recurrence occurred in 2 patients (4.8%) in the VTS group; after 1 and 2 years' follow-up, we proceeded with reoperation. In the second operation, no clear reason for failure was observed, and a T5 sympathectomy was added, resulting in improvement in only 1 patient. The mechanism of recurrence is unknown. The sympathetic system can regain function, although recurrence could also be caused by nervous regeneration or the development of new neural pathways within the spinal medulla.
In the axilla, there are two types of sweat glands: eccrine and apocrine. Eccrine glands are affected by sympathectomy. Apocrine glands are not because they respond primarily to epinephrine [1]. A higher ratio of apocrine glands compared with eccrine glands may explain some poor results of ESB or VTS in AH treatment. The apocrine gland has an important role in bromidrosis. Even though the importance of neural stimulation in apocrine gland function remains uncertain, there is evidence that sympathectomy could reduce or abolish apocrine gland secretion, with subsequent reduction of the bacterial decomposition that causes bromidrosis, resulting in its cure [3, 4]. In the present study, cure or improvement of associated bromidrosis was achieved in 95.4% of patients.
Compensatory sweating can be defined as excessive sweating that appears after sympathectomy or sympathetic block in anatomic areas different from those for which the patient was operated on. The emotional and social difficulties brought on the patients by excessive sweating are usually so great that most patients accept some degree of CS after the operation, provided they are relieved of their hyperhidrosis.
Compensatory sweating has been reported in 30% [13] to 98% [1, 22] of postoperative patients, and its mechanism has not been clearly established. Variable rates of CS have been reported with different levels of sympathectomy: 90.0% with T2T3 [23]; 55.5% [18] and 86.4% [14] with T2T3T4; 84.3% with T2T3T4T5 [24]; and 70% with T3T4 [3]. Leseche and colleagues [11] did not find a correlation between the extension of sympathectomy and CS, but it should be emphasized that in this review all patients had the T2 ganglion resected.
A study of 102 patients showed that a greater body mass index is associated with more severe CS [25]. Therefore, surgeons should discuss this with patients who must lose weight for a surgery and also refuse to operate on obese patients.
Lin and Telaranta [26] suggest that T2 is the ganglion that controls the most afferent sympathetic tonus and its ablation is the mechanism that triggers CS (or reflex sweating, as they prefer to call it). They propose T4 blockage as an effective method of treatment of AH that preserves sympathetic tonus to the head and neck, while reducing the reflex mechanism of CS. The implication of T2 in the genesis of CS is corroborated by others [1, 18, 27–29].
In this study there was no statistical significance between ESB and VTS on the rates, severity, location, and degrees of CS. Contrary to what is found in the literature, in the present study, severe CS did not disappear, did not decrease with time, and was responsible for dissatisfaction in 3.4% of the patients.
The effectiveness of ESB in the treatment of primary hyperhidrosis has been clearly demonstrated by several authors [1, 2, 9, 16, 18, 23, 24, 27–29], but doubt still persists in the treatment of AH in relation to the better level to be used for clipping.
Video thoracoscopic sympathectomy is a safe procedure, with a low rate of complications. The reported mortality rate was zero, until Ojimba and Cameron [6] reported 9 deaths. The effectiveness of VTS has been demonstrated [30–32], but its drawback is that it is irreversible. Sympathetic block by clamping is an alternative to sympathectomy, as it is potentially reversible. In one study, 5 patients had the clip removed in an attempt to reverse the effects of sympathetic block: 3 patients improved within a week and CS was abolished in 2 months, 1 patient had significant reduction of CS and the other patient had no improvement [8]. In another study, 5 of 7 patients who had severe CS owing to previous T4 clipping improved significantly during the following months [1]. In 13 patients who received the reversible procedure, 11 recovered from CS and resumed their previous condition within 2 months, 1 had partial relief, and the others had no improvement [28]. Reversal of sympathectomy can also be performed by interposition of intercostals [33] or sural nerve grafts [1, 33], performed by videothoracoscopy with few satisfactory results.
The multiplicity of techniques reported in the literature, especially on differeing levels of sympathetic section or resection, makes it difficult to analyze the results [34]. However, the results obtained in the present study allow us to conclude that ESB and VTS of T3T4 ganglion are similarly efficient in AH treatment and that there was no difference regarding therapeutic success, incidence, severity, and location of CH, and satisfaction rate between both groups.
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Acknowledgments
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The authors thank Tânia Weigang, of surgical instruments, for her dedication to the work and her competence.
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References
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Abstract
Introduction
