Palmar hyperhidrosis and its surgical treatment: a report of 100 cases

Needle thoracic sympathectomy for essential hyperhidrosis: intermediate-term follow-up

BACKGROUND

Essential hyperhidrosis is a condition with excessive sweating localized to certain part of the body. A definitive cure can be obtained by upper thoracic sympathectomy.

METHOD

Between June and October 1997, 117 patients with essential hyperhidrosis underwent needle thoracoscopic sympathectomy. Of the 94 patients, 42 were men and 52 women. Their ages ranged from 14 to 63 years, with a mean age of 23 years.

RESULTS

There were no mortality or life-threatening complications. Symptomatic improvement was found in 95.7%. Compensatory hyperhidrosis was found in 71.2% of the patients, but in these compensatory hyperhidrosis were mostly tolerable.

CONCLUSIONS

This therapeutic procedure is minimally invasive and very effective. Further development of the new device and surgical technique are expected to follow.

Changes of bilateral palmar skin temperature in transthoracic endoscopic T-2 sympathectomy

OBJECT

Transthoracic endoscopic T-2 sympathectomy is currently the treatment of choice for palmar hyperhidrosis (PH). Intraoperative monitoring of palmar skin temperature (PST) is often used to assess the adequacy of sympathetic ablation. The aim of this study was to investigate the time course of PST changes during the operation and to determine factors involved in the sympathetic modulation of the palmar skin blood flow.

METHODS

Eighty-one patients with PH underwent bilateral transthoracic endoscopic sympathectomy of T-2 in which continuous intraoperative PST monitoring was used. Palmar skin temperature data, recorded every 30 seconds throughout the operation, were plotted against time, and a graph of two PST curves was obtained in each case. A multiphasic curve pattern of great similarity was observed in nearly 70% of cases. Specific PST readings at different operative stages were collected and averaged for all cases. The trend of PST changes in response to different procedures during the operation was analyzed. It was found that unilateral procedures caused simultaneous bilateral PST alterations. In almost all cases, bilateral PST was dramatically lowered when unilateral skin incision and intercostal muscle dissection were performed. The temperature remained low until the T-2 sympathectomy was finished on one side. In addition, unilateral T-2 sympathectomy induced synchronous elevation of bilateral PST. However, the ipsilateral response was significantly stronger than that on the contralateral side.

CONCLUSIONS

Although intraoperative monitoring of PST is a reliable guide for surgeons performing endoscopic transthoracic sympathectomy, it is important to realize that PST fluctuates at different stages during the operation and that surgical procedures themselves can significantly influence PST readings. The PST data recorded at specific time points, therefore, can be misleading in terms of accuracy and the completeness of ablation of the target sympathetic ganglia, especially when the sympathetic trunk or ganglia are anatomically aberrant.

Are We Paying a High Price for Surgical Sympathectomy? A Systematic Literature Review of Late Complications

The purpose of this article was to systematically review the literature in order to assess (1) the current indications for surgical sympathectomy and (2) the incidence of late complications collectively and per indication. All types of upper or lower limb surgical sympathectomies are included. An extensive search strategy looked for controlled trials and observational studies or case series with an english abstract. Out of 1,024 abstracts from MEDLINE and 221 from EMBASE, 135 articles reporting on 22,458 patients and 42,061 procedures (up to april 1998) fulfilled the inclusion criteria. Weighted means were used to control for heterogeneity of data. No controlled trials were found. The main indication was primary hyperhidrosis in 84.3% of the patients. Compensatory hyperhidrosis occurred in 52.3%, gustatory sweating in 32.3%, phantom sweating in 38.6%, and horner's syndrome in 2.4% of patients, respectively, with cervicodorsal sympathectomy, more often after open approach. Neuropathic complications (after cervicodorsal and lumbar sympathectomy) occurred in 11.9% of all patients. Compensatory hyperhidrosis occurred 3 times more often if the indication was palmar hyperhidrosis instead of neuropathic pain (52.3% versus 18.2%), whereas neuropathic complications occurred 3 times more often if the treatment was for neuropathic pain instead of palmar hyperhidrosis (25.2% versus 9.8%). Surgical sympathectomy, irrespective of approach, is accompanied by several potentially disabling complications. Detailed informed consent is recommended when surgical sympathectomy is contemplated.

Long-term results of 45 thoracoscopic sympathicotomies for primary hyperhidrosis in children

BACKGROUND/PURPOSE

Thoracoscopic sympathicotomy (TS) is successful in treatment of excessive hyperhidrosis of the upper limb after limited follow-up observation. The aim of the study was to assess for the first time long-term results of TS in children.

METHODS

A total of 26 children (9 boys, 17 girls) aged 11 to 17 years with severe palmar or axillar hyperhidrosis underwent TS, and 19 patients were treated bilaterally. A total of 19 patients were observed after a median follow-up period of 16 years by questionnaire or clinical examination.

RESULTS

Permanent relief from palmar hyperhidrosis was given in all examined patients. Twelve patients had compensatory and 12 patients gustatory sweating. Postoperatively, 1 subcutaneous emphysema and 1 temporary miosis and ptosis were noted. Eleven patients were fully satisfied with the result. Seven patients were only partially satisfied because of compensatory or gustatory sweating but would again undergo operation. One patient was not satisfied because of excessive compensatory sweating.

CONCLUSIONS

TS is a safe and efficient procedure even after long-term follow-up. Severe palmar hyperhidrosis often starts in childhood; thus, early surgical treatment can improve social development. Compensatory and gustatory sweating are the most frequent and enduring side effects and should be mentioned in preoperative patient and parent information.

Axillary Hyperhidrosis Treatment by Simple Skin Excision and Undermining

The current literature of axillary hyperhidrosis is reviewed. Excision of the gland-containing skin of the axilla has been a mainstay in the treatment of axillary hyperhidrosis for many years. A retrospective study was performed using data accumulated from 56 consecutive patients who underwent a surgical procedure modified from that originally described by Hurley and Shelley. Excision of the hair-bearing portion of the axilla with undermining of the adjacent skin and simple closure was performed under local or general anesthesia. Ninety-two per cent of patients were satisfied with the results. Five patients wished to undergo a second procedure, either because they still had excessive perspiration or because they were unhappy with their scars. Complication rates were low and were compared with other series. Thus, the described procedure provides a simple, safe and effective modality for the treatment of axillary hyperhidrosis.

The Illness Intrusiveness Rating Scale: a measure of severity in individuals with hyperhidrosis

OBJECTIVE

We estimated the reliability and validity of the Illness Intrusiveness Ratings Scale (IIRS) in hyperhidrosis, using an electronic mail form of administration.

METHODS

Recent contributors to an electronic mail discussion group on hyperhidrosis responded to the IIRS, questions about surgical history, items designed to assess severity, and demographic questions, on two occasions four weeks apart. A variety of hypotheses regarding the relationships between these variables were constructed a priori.

RESULTS

Sixty-eight people replied on two occasions. Internal consistency was high (Cronbach's alpha 0.88), as was test-retest reliability (kappa 0.89). The total IIRS score correlated with a global severity question (0.61; p < 0.001). Total IIRS score was lower in participants who had previously had surgery for hyperhidrosis, compared with those who had not (47 vs. 36; p = 0.02), and changed dramatically in the direction of diminished severity in four patients who underwent surgery during the course of the study (54 vs. 17; p = 0.01). Weak-to-moderate correlations were observed between total score and use of topical preparations, use of medications, number of clothing changes during a day, and limitations in choice of wardrobe.

CONCLUSIONS

The IIRS is both reliable and valid in the assessment of patients with hyperhidrosis. A novel form of administration does not appear to affect its properties.

Xenografting human T2 sympathetic ganglion from hyperhidrotic patients provides short-term restoration of catecholaminergic functions in hemiparkinsonian athymic rats

Previous studies have suggested that allografting peripheral sympathetic ganglia, such as superior cervical ganglia, partially relieves clinical or behavioral deficits in parkinsonian patients and animals. However, removal of these ganglia can cause Homer's syndrome, which limits the utilization of this approach. Hyperhidrosis, a disease of excessive sweating, is commonly seen in young Orientals. Treatment of hyperhidrosis often involves surgical removal of the second thoracic sympathetic ganglia (T2G), which contain catecholaminergic neurons. The purpose of our study was to investigate behavioral responses and tyrosine hydroxylase (TH) immunoreactivity in hemiparkinsonian rats at different time points after transplantation of human T2G from hyperhidrotic patients. Athymic Fisher 344 rats were injected unilaterally with 6-hydroxydopamine into the medial forebrain bundle to destroy the nigrostriatal dopaminergic (DA) pathway. The effectiveness of lesions was tested by measuring methamphetamine (MA)-induced rotations. These unilaterally lesioned rats were later transplanted with T2G or T2 fiber tract (T2F) obtained from adult hyperhidrotic patients. Animals grafted with T2G showed a reduction in MA-induced rotation by 2 weeks; however, rotation returned to the pregrafting levels by 3 months. Animals receiving T2F grafts did not show any reduction of rotation over a 3-month period. Animals were later sacrificed for TH immunostaining at different time points. Tyrosine hydroxylase-positive [TH(+)] cell bodies and fibers were found in the lesioned striatum 2-4 weeks after T2G grafting, suggesting the survival of transplants. Two to 3 months after grafting, TH(+) fibers were still found in almost all the recipients. However, TH(+) cell bodies were found in only three of seven rats studied. Animals receiving T2F grafting did not show any TH immunoreactivity in the lesioned striatum over the 3-month period. These data indicate that T2G transplants from adult hyperhidrotic patients can survive and provide transient normalization of the motor behavior in the hemiparkinsonian athymic rats. Because of the short-term improvement in behavior after grafting, the use of T2G in human trials should be cautious at the present time. Further laboratory research is required.

Transthoracic endoscopic sympathectomy in the treatment of palmar hyperhidrosis--with emphasis on perioperative management (1,360 case analyses)

BACKGROUND

Primary palmar hyperhidrosis (PH) is very common, and can be disabling. Various surgical methods for endoscopic sympathectomy have been advocated. We present a simple and effective method of treating PH by means of transthoracic endoscopic sympathectomy (TES).

METHODS

From July 1994 to May 1998, a total of 1,360 patients with hyperhidrosis palmaris underwent TES. There were 544 males and 816 females with a mean age of 23.1 years old (range, 5 to 60 years). All patients were placed in a half-sitting position under single-lumen intubational anesthesia. We performed the ablation of the T2 ganglion using either a 6- or 8-mm, 0-degree thoracoscope (Karl Storz Company, Germany)

RESULTS

In these 1,360 patients, 2,715 sympathectomies were performed. TES was usually accomplished within 15 min. Surgical complications were minimal: six cases of pneumothorax (0.44%), four cases of segmental collapse of lung (0.29%), and two wound infections (0.15%). There was no surgical mortality. The mean postoperative follow-up period was 27.8 months. A total of 1,292 patients (95%) had highly satisfactory results, although 1,140 patients (84%) have developed compensatory sweating of the trunk and lower limbs. The affected area was the axillae, back, abdomen, lower limbs (16%, 82%, 52%, and 78%, respectively). The recurrence rates of PH were 0.4% in the first year, 0.6% in the second year, and 1.1% in the third year.

CONCLUSIONS

TES is a simple, safe, and effective method of treating PH.

Current practice in thoracic sympathectomy

Thoracic sympathectomy has been performed for many years. With the recent development of video assisted thoracic surgical techniques the indications for surgery have increased, and the outcome is much better.

Video assistance reduces complication rate of thoracoscopic sympathicotomy for hyperhidrosis

BACKGROUND

Thoracoscopic sympathicotomy has proved successful in the treatment of palmar hyperhidrosis. However, up to 8% of patients experience Horner's syndrome, and about 50% show compensatory sweating. This study evaluates the role of video assistance in thoracoscopic sympathicotomy for primary hyperhidrosis of the upper limb.

METHODS

Six hundred fifty-six thoracoscopic sympathicotomies were performed from below T1 to T4 in 369 patients. Of the operations, 558 were done under direct view (CTS group) and 98, with video assistance (VATS group). Follow-up was complete for 78.3% of patients after a median observation period of 16 years.

RESULTS

Dry limbs were immediately achieved in 93% of the CTS group and 98% VATS group (p = 0.98). In the CTS group, Horner's syndrome occurred after 2.2% of all operations and rhinitis in 8.3%. No patient in the VATS group showed any symptom of Homer's triad (p = 0.03 versus CTS group) or rhinitis (p = 0.02 versus CTS group). Compensatory sweating was observed in 66.8% in the CTS group versus 69% in the VATS group (p = 0.73) and gustatory sweating, in 50.4% versus 27.6%, respectively (p = 0.01).

CONCLUSIONS

In performing thoracoscopic sympathicotomy for excessive upper-limb hyperhidrosis, we observed a significant decrease in the incidence of Horner's syndrome, rhinitis, and gustatory sweating when the procedure was guided by video imaging.

Transthoracic endoscopic sympathectomy for palmar hyperhidrosis in children and adolescents: analysis of 350 cases

Primary palmar hyperhidrosis (PH) often commences in childhood and adolescence and can be a disabling condition. There are few reports regarding endoscopic sympathectomy for PH in children and adolescents. Therefore, I present our experience with transthoracic endoscopic sympathectomy (TES) in treating PH in children and adolescents. From July 1994 to March 1998, a total of 350 patients underwent TES. There were 93 males and 257 females with a mean age of 12.9 years (range 5-17 years). All patients were placed in a half-sitting position under single-lumen intubated anesthesia. We performed ablation of the T2 ganglion using either a 6- or an 8-mm 0 degree thoracoscope (Karl Storz Company, Germany) via one 0.8-cm incision just below each axilla. Among these 350 patients, 699 sympathectomies were performed. Usually, TES was accomplished within 15 minutes (range 7-20 minutes). The surgical complications were minimal: one pneumothorax and one segmental lung collapse. There were no surgical deaths. With a mean postoperative follow-up period of 25 months (range 5-44 months), the result of TES was highly satisfactory in 331 patients (94.6%), although 301 patients (86%) developed compensatory sweating of the trunk and lower limbs, the distribution being the axillae (12%), back (86%), abdomen (48%), or lower limbs (78%). The recurrence rates of palmar hyperhidrosis were 0.6% in the first year, 1.1% in the second year, and 1.7% in the third year. Transthoracic endoscopic sympathectomy is a safe and effective method for treating PH in children and adolescents.

The long-term results of upper dorsal sympathetic ganglionectomy and endoscopic thoracic sympathectomy for palmar hyperhidrosis

To assess and compare the long-term results of upper dorsal sympathetic ganglionectomy (UDS) and endoscopic thoracic sympathectomy (ETS), we examined 84 patients who underwent UDS and 71 patients who underwent ETS for the treatment of palmar hyperhidrosis. The period of follow-up ranged from 37 to 228 months. The immediate success rate was 100% in the UDS group and 98.6% in the ETS group. Troublesome compensatory hyperhidrosis occurred in 67.8% of the UDS patients and 84.8% of the ETS patients; however, 55% of the UDS patients and 63% of the ETS patients felt satisfied with their operation. The main reasons for dissatisfaction were recurrence and compensatory hyperhidrosis. Interestingly, simultaneous cure of plantar hyperhidrosis occurred in 28 (40%) of the UDS patients and 28 (44%) of the ETS patients with concomitant plantar hyperhidrosis. ETS required both a shorter operation time and hospital stay than UDS. Thus, we now perform ETS as the treatment of choice because of its excellent illumination and adequate magnification via a minimally invasive approach. The use of ETS as the first choice of treatment for palmar hyperhidrosis is supported not only by the immediate results, complications, and cure of plantar hyperhidrosis, but also by the long-term results. Nevertheless, compensatory hyperhidrosis was also a major complication after ETS.

The results of thoracoscopic sympathetic trunk transection for palmar hyperhidrosis and sympathetic ganglionectomy for axillary hyperhidrosis

OBJECTIVES

To review our total experience of thoracoscopic sympathetic trunk transection for the treatment of palmar hyperhidrosis and second and third thoracic sympathetic ganglionectomy for axillary hyperhidrosis.

DESIGN

Longitudinal cohort study following up consecutive patients for 0.3 to 5.5 years.

SUBJECTS

Fifty-four consecutive patients undergoing thoracoscopic sympathectomy for hyperhidrosis.

METHODS

Prospective evaluation of immediate technical success, complications, late recurrence of hyperhidrosis and patient acceptability.

RESULTS

100% initial cure for palmar hyperhidrosis, 91% of sympathetic ganglionectomies for axillary hyperhidrosis were technically successful and initially curative. Compensatory sweating 44% patients, most severe after bilateral sympathetic ganglionectomy. Complications occurred in 14% patients, all resolving without further intervention. There were no cases of Horner's syndrome. 13% patients reported a return of some palmar sweating. 5.4% patients developed recurrent palmar hyperhidrosis at 6, 15 and 21 months postoperatively.

CONCLUSION

Transection of the sympathetic trunk between the first and second thoracic sympathetic ganglia initially cures 100% of patients treated primarily for palmar hyperhidrosis. Technically successful 2nd and 3rd thoracic sympathetic ganglionectomy initially cures 100% of patients with axillary hyperhidrosis. Compensatory sweating is common after bilateral sympathectomy. Recurrent palmar hyperhidrosis occurs in 5.4% of cases, but can be cured by a second thoracoscopic sympathectomy. Horner's syndrome is an avoidable complication of thoracoscopic sympathectomy.

Resympathectomy for palmar and axillary hyperhidrosis

BACKGROUND

The aim was to analyse patterns of failure or symptom recurrence after primary sympathectomy for palmar or axillary hyperhidrosis, and to carry out tactical problem-solving for resympathectomy and review the operative findings.

METHODS

Over a 2-year period, 20 patients (six men and 14 women) underwent resympathectomy for palmar hyperhidrosis (13 patients, 20 sides) or axillary hyperhidrosis (seven patients, ten sides). T2-3 sympathectomy for palmar hyperhidrosis or T4-5 sympathectomy for axillary hyperhidrosis was performed during the repeat procedure. Criteria for evaluation by means of patient questionnaire included good (more than 80 per cent), fair (50-80 per cent) and poor (less than 50 per cent) improvement.

RESULTS

Operative findings included inadequate sympathectomy on 19 sides, nerve regeneration on eight sides and no evidence of previous sympathectomy on three sides. One patient had Kuntz fibre in addition to inadequate sympathectomy. In the palmar hyperhidrosis group, good results were obtained in all 13 patients on all 20 sides after resympathectomy. In the axillary hyperhidrosis group, six of seven patients, or eight of ten sides, showed good results after resympathectomy.

CONCLUSION

The main cause of primary sympathectomy failure was inadequate surgery, and recurrence of palmar or axillary hyperhidrosis was seldom caused by nerve regeneration. The key factor for preventing failed sympathectomy or recurrent palmar or axillary hyperhidrosis is a first-time sympathectomy that is both accurate and adequate. Most patients with recurrent symptoms can be cured by resympathectomy.

Endoscopic transthoracic dorsal sympathectomy for the treatment of upper extremity hyperhidrosis: a new minimally invasive approach

Palmar and axillary hyperhidrosis are best treated surgically by endoscopic transthoracic upper dorsal sympathectomy. At present, this methodology relies on (at least) double trocar insertion (per side), carbon dioxide insufflation, or both. We present a new minimally invasive endoscopic transthoracic technique, performed by a single-entry specifically modified thoracoscope and without the need for carbon dioxide insufflation, with the aim to reduce the drawbacks associated with the above-mentioned, currently adopted endoscopic technique. In our opinion, this "single-entry" technique, compared with the other reported approaches, should theoretically minimize any damage to the intercostal neurovascular bundle, while avoiding the complications related to carbon dioxide insufflation.

Sympathetic skin response and patient satisfaction on long-term follow-up after thoracoscopic sympathectomy for hyperhidrosis

OBJECTIVES

To determine effect of sympathectomy for hyperhidrosis on sympathetic skin response (SSR) during long-term follow-up. Patient satisfaction was assessed and surgical complications noted.

DESIGN

Prospective, Open, Non-randomised study.

MATERIALS AND METHODS

Patients who had undergone bilateral thoracoscopic sympathectomy for hyperhidrosis underwent postoperative assessment of SSRs. A 15 mA stimulus was applied over the median nerve contralateral to the sympathectomy and evoked electrodermal activity was recorded from the sympathectomised palm using a Dantec Counterpoint Mk 2. Patient satisfaction with surgery was assessed by questionnaire and visual analogue score (0-1.0).

RESULTS

Of 26 patients, 21 were female. Mean (range) age was 23 (9-36) years. Mean (range) follow up was 39 (4-138) months. 12% of cases had residual or recurrent symptoms. Median (range) patient satisfaction was 0.83 (0.06-1.0). In 7/52 palms recurrent SSRs were not detected. Repeated measures analysis of variance found amplitude of SSR to be of low significance with respect to time since surgery (F = 0.48; p = 0.49) and incidence of compensatory sweating (F = 2.38; p = 0.14).

CONCLUSION

Thoracoscopic sympathectomy for hyperhidrosis is an effective procedure. Following sympathectomy SSRs are not permanently abolished, but return of SSRs does not correspond with symptom recurrence. As such, SSRs are a poor tool for objective assessment of long-term outcome following sympathectomy.

Complications in patients with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy

OBJECTIVE

To assess the complications in a group of patients with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy. The extraordinarily high incidence of postoperative compensatory hyperhidrosis in our series is stressed and explained.

METHODS

The retrospective study included chart reviews and outpatient assessments. Seventy-two patients underwent T2 or T2-T3 endoscopic sympathectomy for primary palmar hyperhidrosis. Patients' hyperhidrosis severity, precipitating factors, postoperative complications, surgical results, and satisfaction were assessed. Severity of palmar hyperhidrosis and compensatory hyperhidrosis was classified by two grading scales.

RESULTS

The success rate of sympathectomy was 93%. All patients except one suffered from compensatory sweating, which was the main cause of patients' dissatisfaction postoperatively. Seventeen percent of the patients (12 of 72 patients) experienced new symptoms of gustatory sweating (facial sweating associated with eating). Twenty-one patients experienced other complications, including pneumothorax, Horner's syndrome, nasal obstruction, and intercostal neuralgia.

CONCLUSION

Transthoracic endoscopic sympathectomy is an effective and simple modality to treat palmar hyperhidrosis. However, all patients need to be warned of the common complications, particularly compensatory hyperhidrosis, before surgery.

Altered response in cutaneous sympathetic outflow to mental and thermal stimuli in primary palmoplantar hyperhidrosis

Skin sympathetic nerve activities (SSNAs) were recorded simultaneously from the tibial and peroneal nerves by microneurography at an ambient temperature of 25 degrees C in five subjects with primary palmoplantar hyperhidrosis. The resting of the tibial SSNA innervating the sole (glabrous skin) increased moderately (36.5 +/- 1.5 bursts/min), while mental arithmetic provoked marked responses (1,003.3 +/- 457.4% compared with the resting level) in the hyperhidrosis group compared with the control normohidrosis group (n = 5, 25.3 +/ 4.2 bursts/min and 142.2 +/- 58.4%, respectively). Differentiation of the tibial SSNA into sudomotor (innervating sweat glands) and vasoconstrictor (innervating presphincter of skin vessels) revealed that this SSNA enhancement was attributable to not only sudomotor but also vasoconstrictor components during mental arithmetic. In contrast, the responses in the peroneal SSNA (innervating the dorsum pedis, hairy skin) of the hyperhidrosis group were only slightly changed, exhibiting no significant difference from those in the normohidrosis group. Reflex bursts elicited by sound and electric stimulation were normal in amplitude and latency. When the ambient temperature was elevated to 30 degrees C, the tibial SSNAs became more enhanced than did the peroneal SSNAs. The tibial SSNA was markedly enhanced in the hyperhidrosis group (290.0 +/- 78.5%) compared with the normohidrosis group (78.3 +/- 25.4%). We conclude that the excessive responses in SSNA to the plantar glabrous skin to both mental and thermal stimuli may be responsible for the profuse sweating in subjects with primary palmoplantar hyperhidrosis.

Effects of non-pharmacological sympathetic sudomotor denervation on sweating in humans with essential palmar hyperhidrosis

OBJECTIVE

Quantitative sweat production and -ionic composition in Essential Hyperhidrosis (EH), and the effects of T2-T3 thoracoscopic sympathicolysis (TS) hereon, are unknown. Standardised pilocarpine iontophoresis sweat tests were performed before and after TS in order to study these issues.

DESIGN AND METHODS

Pilocarpine iontophoretic sweat tests measuring maximal sweat production (mg) and sweat Na+, K+ and Cl- concentrations (mMol/L) were performed on both forearms of 10 EH patients, before and six weeks after TS, and in normal volunteers.

RESULTS

As compared to normals, preoperative maximal sweat production was 30% higher (199.4 +/- 68.8 (SD) vs. 150.6 +/- 45.6 mg) in EH patients; due to type II error, however, statistical significance was not reached. Na+ and Cl- concentrations were similar, and K+ concentration was slightly lower in EH patients. After TS, sweat production had decreased to equal levels as in normals (149.1 +/- 52.1 mg), whereas the Na+ (from 33.6 +/- 6.9 to 51.0 +/- 6.4 mMol/L), Cl- (from 21.5 +/- 6.6 to 37.2 +/- 7.1 mMol/L) and K+ (from 7.5 +/- 1.3 to 8.6 +/- 2.2 mMol/L) concentrations had increased.

CONCLUSIONS

EH patients present 30% higher maximal sweat production at their forearms. This increase may be due to an increased activity of the adrenergic component of sweat gland innervation. The post-TS increase in Na+, Cl- and K+ concentrations suggests that the adrenergic component of sweat gland innervation in itself decreases sweat ion concentrations.

Patterns of sympathetic skin response in palmar hyperhidrosis

Sympathetic skin responses (SSRs) were studied in 44 patients with palmar hyperhidrosis. The mean age was 19 +/- 4 years and the mean age of onset 9.1 +/- 3.6 years. Palmar SSRs were evoked by median nerve stimulation and by magnetic stimulation of the neck. Four types of SSR were identified: normal response, small-amplitude response, multiphasic response and absent response. Four palmar conditions were also identified: warm-wet in 26 patients, warm-dry in seven, cold-wet in seven, and cold-dry in four. Normal SSRs were present in about 25% of patients and absent SSRs in another 25%. The other two types of SSR were evenly distributed among patients, except those with cold-dry palms, who only had absent responses. There was no apparent difference between centrally and peripherally activated SSRs. It is concluded that skin temperature and moisture of the palms play an important role in producing different types of SSR in palmar hyperhidrosis.

Total intravenous anesthesia and high-frequency jet ventilation during transthoracic endoscopic sympathectomy for treatment of essential hyperhidrosis palmaris: a new approach

OBJECTIVE

To evaluate the effects of high-frequency jet ventilation (HFJV) applied to both lungs on hemodynamic parameters, oxygenation, and operating conditions during bilateral videothoracoscopic sympathectomy.

DESIGN

A prospective, unblinded study.

SETTING

An ambulatory surgical unit at a university medical center.

PARTICIPANTS

30 patients (11 men, 19 women), ASA status 1.

INTERVENTION

Bilateral videothoracoscopic sympathectomies were performed using total intravenous anesthesia with propofol, alfentanil, and atracurium, and the patients were ventilated with an oxygen-air mixture using HFJV delivered to both lungs with a Hi-Lo Jet tracheal tube (Mallinckrodt).

MEASUREMENTS AND MAIN RESULTS

Mean total anesthesia time was 55 +/- 13 minutes. Hemodynamic parameters remained stable during surgery, although ablation of the sympathetic ganglia induced three incidences of bradycardia (10% of the patients), which were responsive to atropine. Four patients developed oxygen desaturation (Sa O2 < 90%) after the creation of the pneumothorax. Surgical conditions were considered excellent by the surgeons. Concerning postoperative complications, a temporary Horner's syndrome was observed in one patient. Another patient had a mild residual pneumothorax on the first postoperative day that resolved without insertion of a chest tube.

CONCLUSIONS

It was concluded that HFJV applied to both lungs is an easy and safe anesthetic technique that provides excellent surgical conditions and causes a minor incidence of morbidity.

Changes in cardiocirculatory autonomic function after thoracoscopic upper dorsal sympathicolysis for essential hyperhidrosis

Essential hyperhidrosis (EH) is caused by an unexplained overactivity of the sympathetic fibers which pass through the upper dorsal sympathetic ganglia D2 and D3. Since the D2 and D3 ganglia are also involved in the sympathetic cardiac innervation, cardiocirculatory autonomic function may also be abnormal in EH. In order to study the function of the sympathetic nervous system in EH, and to assess the effects of thoracoscopic sympathiocolysis, cardiocirculatory autonomic function tests were performed in 13 consecutive patients with EH, before (baseline) and 6 weeks after the thoracoscopic intervention. Baseline data were also compared with data obtained from 13 matched healthy volunteers: EH patients showed an increased heart rate at rest, but only in the standing position (94 +/- 18.5 vs 78 +/- 10.9 bpm, P < 0.01), as well as an increased ratio of low to high frequency power of the heart rate variability in the standing position (5.92 +/- 4.4 vs 2.8 +/- 2.5, P < 0.05). Exercise tests were normal in every EH patient. After sympathiocolysis, heart rate at rest (sitting on the cycloergometer) had decreased (75.4 +/- 13 vs 90.4 +/- 16.5 bpm, P < 0.05), as well as heart rate at maximal exercise (165.2 +/- 14.8 vs 180 +/- 10 bpm, P < 0.05). Exercise capacity and the cardiorespiratory responses to exercise were, however, unchanged after sympathicolysis. Resting heart rate in the lying (66 +/- 10 vs 76 +/- 15 bpm, P < 0.05) and standing positions (82 +/- 13.8 vs 94 +/- 18.5 bpm, P < 0.05), and the diastolic blood pressure reaction to a handgrip test (73.6 +/- 8.6 vs 84.7 +/- 11.6 mmHg, P < 0.05) were also lowered after sympathicolysis. In conclusion, patients with EH show an overfunctioning of the sympathetic system which is characterised by an increased reaction to stress (standing, exercise), whereas resting sympathetic tone is unaffected. Thoracoscopic D2-D3 sympathicolysis corrects this hyperfunction and has a partial beta-blocker-like activity, which results in a decrease in heart rate at rest and during maximal exercise, and in the diastolic blood pressure response to the handgrip test. Further studies are needed to assess the long-term consequences of this procedure.

Upper dorsal thoracoscopic sympathectomy for palmar hyperhidrosis: improved intermediate-term results

PURPOSE

The purpose of this study was to examine the immediate and mid-term results of thoracoscopic upper dorsal (T2-T3) sympathectomy for primary palmar hyperhidrosis.

METHODS

From June 1993 to October 1994 we performed 106 sympathectomies on 53 patients with palmar hyperhidrosis. Thirty-four female patients and 19 male patients ranging in age from 15 to 44 years, (mean 23.1 years) were studied. Both sides were operated during the same surgical procedure. The T2-T3 ganglia were resected by electrocuting with a hook and were removed for histologic examination. Follow-up for a mean of 19.25 months was obtained on 52 patients (104 operated limbs).

RESULTS

All limbs were completely dry at the end of the procedure, and hyperhidrosis did not recur during the whole follow-up period. Short-term postoperative complications (mainly atelectasis, pneumonia, pneumothorax, and hemothorax) occurred in six (11.3%) patients. Long-term sequelae were observed in 43 (81.1%) patients and included Horner's syndrome (9 patients, 17.3%, one side only in each patient), neuralgia (7 patients, 13.5%), and compensatory hyperhidrosis (35 patients, 67.3%). These sequelae were not permanent in all cases, and the degree of severity was variable. Six (11.5%) patients, three of whom regretted being operated, were dissatisfied with their results: one because of Horner's syndrome, one because of persisting neuralgia, and four because of compensatory sweating.

CONCLUSIONS

Despite the large number of postoperative long-term sequelae, 88.5% of patients expressed subjective satisfaction from the procedure. Obtaining 100% of dry hands on mid-term follow-up makes this approach rewarding.

Contralateral temperature changes of the finger surface during video endoscopic sympathectomy for palmar hyperhidrosis

One hundred and eight consecutive patients with primary palmar hyperhidrosis were surgically managed by coagulation of bilateral T2 sympathetic ganglia using video thoracoscopic techniques. Patients were divided into two groups. In the first group (N = 46), finger surface temperature of the ipsilateral index finger was recorded before and after T2 ganglionectomy. The average increase of post-operative temperature was 2.74 +/- 0.27 degrees C (mean +/- SE) on the right side and 2.67 +/- 0.33 degrees C on the left (P < 0.05). The significant rise of temperature resulting from sympatholytic vasodilatation was only noted in cases of exact ablation of the T2 ganglion. In the second group (N = 62), surface temperatures of both index fingers were monitored and recorded simultaneously. These patients were arbitrarily subdivided into Group 2-A (N = 29) when right side ganglionectomy was performed first and Group 2-B (N = 33) when left side ganglionectomy was done initially. After the first ganglionectomy was completed, an ipsilateral increase with a contralateral decrease of temperature was observed; the average increase of temperature was 1.92 +/- 0.35 degrees C and 2.19 +/- 0.30 degrees C, and the average decrease was 1.50 +/- 0.51 degrees C and 1.67 +/- 0.39 degrees C for Group 2-A and 2-B respectively (P < 0.05). The authors postulate that a cross-inhibitory effect by the post-ganglionic neurons innervating blood vessels of the upper extremities may exists in humans and this effect is released after ganglionectomy, resulting in contralateral vasoconstriction and decrease of finger surface temperature.

Advantages of limited thoracoscopic sympathectomy

BACKGROUND

Thoracoscopic resection of the first through the fourth thoracic sympathetic ganglion for palmary and axillary hyperhidrosis and Raynaud's syndrome is associated with a high initial success rate. However, the reported incidence of compensatory hyperhidrosis of the trunk and legs and Horner's syndrome are high. This study assesses the results of thoracoscopic sympathectomy limited to transection of the interganglionic trunk or resection of one or two thoracic ganglia.

METHODS

Twenty-eight thoracoscopic sympathectomies were done for dystrophy of the hand (n = 9), palmar and axillary hyperhidrosis (n = 6), and Raynaud's syndrome (n = 4). The extent of sympathectomy varied from interganglionic division between the second and third ganglion (n = 12), to resection of the third ganglion (n = 12), to resection of the second and third ganglion (n = 4).

RESULTS

Sympathectomy resulted initially in relief of symptoms in all cases. Horner's syndrome did not occur.

CONCLUSIONS

After a median follow-up of 11 months, two of nine patients with dystrophy judged the result of operation as good. All patients with hyperhidrosis and Raynaud's syndrome judged the result of sympathectomy as good. Compensatory hyperhidrosis was experienced by two patients with dystrophy of the hand who had removal of the second and third sympathetic ganglion.

A simplified T2-T3 thoracoscopic sympathicolysis technique for the treatment of essential hyperhidrosis: short-term results in 100 patients

A simplified one-time bilateral thoracoscopic T2-T3 sympathicolysis technique using single-lumen endotracheal intubation with high frequency jet ventilation and electrocautery destruction ("sympathicolysis") of the sympathetic ganglia was applied in 100 consecutive patients with severe essential hyperhidrosis (EH). Providing a pleural space can be created, this technique was proven simple and safe, and short-term clinical results were excellent: palmar hyperhidrosis was cured in 98% of patients, and axillar and plantar improvement was achieved in 62 and 65% of patients, respectively. Side-effects and complications were minor (compensatory hyperhidrosis) or self-limiting (pain). These data confirm the safety and efficacy of thoracoscopic sympathetic interventions for the treatment of EH, and support the evolution toward simplified methodologies.

Transthoracic endoscopic sympathectomy for primary palmar hyperhidrosis in children

Primary palmar hyperhidrosis often starts in childhood. It usually causes academic and social disabling at the age children begin primary school. This study included 65 children (44 girls and 21 boys, mean age 13.5 years) who underwent one-stage bilateral transthoracic endoscopic sympathectomy. The proper sympathetic segment was visualized in almost all cases and electrocautery ablation was performed. The immediate postoperative course was uneventful in all cases and no major morbidity was encountered. Horner's syndrome did not occur in any case. All patients were discharged the day of surgery or after an overnight stay. The duration of follow-up was from 6 months to 3 years. Although compensatory sweating was found in 40% of the patients, long-term satisfaction was reported in 63 cases (96%). This procedure is effective, simple, and is recommended as the method of choice for surgical treatment of severe upper extremity hyperhidrosis in children.

Video endoscopic sympathectomy for palmar hyperhidrosis

Palmar hyperhidrosis has been treated using a variety of medical and surgical techniques with varying degrees of success. The authors report their experience in 82 patients in whom they performed 164 sympathectomies using a video endoscope, a laparoscopic grasper, and microscissors. Patients were monitored by palm temperature electrodes. An intraoperative histological confirmation of the sympathetic chain and a temperature rise of at least 1 degree C after the procedure resulted in complete relief of the hyperhidrosis. All the patients were relieved of their symptoms, and 41 experienced decreased plantar hyperhidrosis as well. Compensatory hyperhidrosis in 50 patients was the only significant side effect, which improved 6 months after the surgery. Video endoscopic thoracic sympathectomy is a safe, easy, reliable, and cost-effective way to treat palmar hyperhidrosis.

Left, but not right, one-lung ventilation causes hypoxemia during endoscopic transthoracic sympathectomy

OBJECTIVE

To describe the respiratory and cardiovascular effects of one-lung ventilation, using a double-lumen tube, during endoscopic transthoracic sympathectomy.

DESIGN

A prospective clinical study.

SETTING

A university-affiliated medical center.

PARTICIPANTS

Nineteen adult patients (10 men, 1 woman) between 16 and 35 years of age, ASA (American Society of Anesthesiologists) physical status I and II, participated in the study.

INTERVENTIONS

Endoscopic transthoracic sympathectomy was performed under general anesthesia, using a double-lumen endobronchial tube, after induction of artificial pneumothorax plus insufflation of CO2 into the operated chest. Via radial artery cannulae, one to three arterial blood gas samples were taken during two-lung ventilation before surgery, at each one-lung ventilation, in most cases during the period of two-lung ventilation when switching between the operated sides, and after surgery.

MEASUREMENTS AND MAIN RESULTS

Comparisons were performed using the Wilcoxon matched-pairs single-ranks test. Left-lung ventilation and right-chest operation caused profound decrease of arterial oxygen partial pressure (PaO2), compared with two-lung ventilation before surgery (70.7%, P > 0.0003) and compared with PaO2 at two-lung ventilation during and after surgery (decrease of 80.1% and 75.3%, respectively; P > 0.001 and < 0.005, respectively). Right-lung ventilation and left-chest operation did not cause hypoxemia. Arterial CO2 partial pressure, pH, and bicarbonate, as well as hemodynamic parameters, did not change from baseline values throughout surgery.

CONCLUSIONS

Pulse oximetry and repeated blood gas measurements are needed during endoscopic transthoracic sympathectomy in order to detect and treat hypoxemic events, which may jeopardize the patient's life.

Post-sympathectomy neuralgia: hypotheses on peripheral and central neuronal mechanisms

Post-sympathectomy neuralgia is proposed here to be a complex neuropathic and central deafferentation/reafferentation syndrome dependent on: (a) the transection, during sympathectomy, of paraspinal somatic and visceral afferent axons within the sympathetic trunk; (b) the subsequent cell death of many of the axotomized afferent neurons, resulting in central deafferentation; and (c) the persistent sensitization of spinal nociceptive neurons by painful conditions present prior to sympathectomy. Viscerosomatic convergence, collateral sprouting of afferents, and mechanisms associated with sympathetically maintained pain are all proposed to be important to the development of the syndrome.

Cardiopulmonary exercise testing following bilateral thoracoscopic sympathicolysis in patients with essential hyperhidrosis

BACKGROUND

Essential hyperhidrosis is characterised by an overactivity of the sympathetic fibres passing through the upper dorsal sympathetic ganglia D2-D3. Anatomical interruption at the D2-D3 level is a highly effective treatment for essential hyperhidrosis but also causes (partial) cardiac denervation and, after surgical sympathicolysis, important impairment of cardiopulmonary exercise function has been observed. The purpose of this study was to compare the results of cardiopulmonary exercise testing between patients with essential hyperhidrosis and a normal control population, and to examine the effects of thoracoscopic D2-D3 sympathicolysis on cardiopulmonary exercise capacity in patients with essential hyperhidrosis.

METHODS

maximal, symptom limited incremental exercise tests were performed in 26 patients with severe essential hyperhidrosis one week before and one month after D2-D3 thoracoscopic sympathicolysis, and in 14 age and sex matched healthy volunteers. D2-D3 thoracoscopic sympathicolysis was performed using a simplified one stage bilateral procedure.

RESULTS

Palmar hyperhidrosis was relieved in every patient, confirming the D2-D3 denervation. A higher peak heart rate (7%) was seen in the patient group than in the normal subjects, but ll other cardiovascular, metabolic, and respiratory parameters were similar. After D2-D3 thoracoscopic sympathicolysis, heart rate at rest (13%) and at peak exercise (7%) were reduced, together with an increase in oxygen pulse. All other parameters remained unchanged.

CONCLUSIONS

Sympathetic overactivity relevant to cardiovascular function in essential hyperhidrosis is evident only during sympathetic stimulation. D2-D3 thoracoscopic sympathicolysis causes a small and asymptomatic reduction in maximal and resting heart rate and is not associated with a decrease in exercise capacity, in contrast with the detrimental effects on exercise capacity of open surgical sympathectomy.

Complications of endoscopic thoracic sympathectomy

BACKGROUND

Endoscopic resection of the thoracic sympathetic trunk has been performed in various diseases of the upper limb. The success rates in endoscopic techniques and open surgical procedures are reportedly between 95% and 100%. However, the incidence of complications varied significantly depending on the technique used. We report our experience with complications after endoscopic resection of the thoracic sympathetic trunk.

METHODS

To evaluate the complications of endoscopic thoracic sympathectomy, we retrospectively investigated 412 patients operated on since 1965. In 412 patients 698 procedures had been performed: a bilateral trunk resection in 81.9%, right thoracic sympathectomy in 12.9%, and left sympathetic trunk resection in 5.2%.

RESULTS

Complications demanding intervention were found in 2.7% of the procedures, and in 9.7% complications not indicating active therapy were seen. In all cases requiring intervention a pneumothorax that needed to be drained was found on postoperative x-ray film. An asymptomatic small apical pneumothorax was found in 4.4%, cutaneous emphysema in 2%, pleural effusion in 1.1%, and segmental atelectasis in 0.4% of the procedures. One case of bleeding from an intercostal vessel occurred (0.1%). A permanent Horner's ptosis was seen in 1.7% of the patients.

CONCLUSIONS

The endoscopic resection of the thoracic sympathetic trunk is a safe and minimally invasive procedure with a low complication rate. We believe that endoscopic sympathectomy should be preferred to open surgical procedures.

Endoscopic transthoracic sympathectomy: an efficient and safe method for the treatment of hyperhidrosis

BACKGROUND

Hyperhidrosis of the palms, axillae, and face has a strong negative impact on the quality of life for many persons. Existing nonsurgical therapeutic options are far from ideal. Definitive cure can be obtained by upper thoracic sympathectomy. The traditional open surgical technique is a major procedure; few patients and doctors have found that risk-benefit considerations favor surgery. Endoscopic minimal invasive surgical techniques are now available.

OBJECTIVE

We investigated whether endoscopic ablation of the upper thoracic sympathetic chain is efficient and safe in the treatment of hyperhidrosis.

METHODS

We treated 850 patients with bilateral endoscopic transthoracic sympathectomy.

RESULTS

There was no mortality or life-threatening complication. Nine patients (1%) required intercostal drainage because of hemothorax or pneumothorax. Treatment failure occurred in 18 cases (2%) and symptoms recurred in 17 patients (2%). At the end of follow-up (median, 31 months) 98% of the patients reported satisfactory results.

CONCLUSION

Endoscopic transthoracic sympathectomy is an efficient, safe, and minimally invasive surgical method for the treatment of palmar, axillary, and facial hyperhidrosis.

Thoracoscopic upper thoracic sympathectomy for primary palmar hyperhidrosis in children and adolescents

After 20 years of experience with the "open" transaxillary approach, the authors are presently performing the thoracoscopic technique for upper thoracic sympathectomy in severe primary hyperhidrosis. During a period of 14 months, 23 operations were performed and 22 patients had immediate and permanent relief of palmar sweating. The immediate postoperative course was uneventful in all cases. Hospitalization was short, and all patients returned to school and full activity 3 to 5 days after operation. These initial results compare favorably to the "open" method and, pending further experience, are actually better in terms of less pain, early discharge, quicker return to normal activity, and a smaller, less conspicuous scar.

Transthoracic endoscopic sympathectomy for hyperhidrosis and Raynaud's phenomenon

Over an 80 month period, 53 transthoracic endoscopic sympathectomies were performed in 34 patients. The indications for surgery were palmar hyperhidrosis in 20 procedures (38%), palmar and axillary hyperhidrosis in eight procedures (15%), Raynaud's phenomenon in 23 procedures (43%), and combined palmar hyperhidrosis and Raynaud's phenomenon in two procedures (4%). Follow-up data, obtained by a self-assessment postal questionnaire, was available for 47 procedures in 30 patients (91%). Fourteen out of 15 procedures (93%) performed for palmar hyperhidrosis, all eight procedures (100%) for palmar and axillary hyperhidrosis and 14 out of 22 procedures (64%) performed for Raynaud's phenomenon produced an immediate improvement in symptoms. These improvements were sustained in 13 procedures (87%) performed for palmar hyperhidrosis, all procedures performed for palmar and axillary hyperhidrosis (100%) but only 10 procedures (45%) performed for Raynaud's phenomenon at a median follow-up of 16, 34 and 44.5 months respectively. There were no deaths nor postoperative Horner's syndrome in these patients. The only minor complications were two small pneumothoraces. Compensatory sweating was observed after 24 procedures (51%). These results confirm that transthoracic endoscopic sympathectomy is a simple, safe and effective procedure. In patients with hyperhidrosis, the results are excellent and prolonged; in patients with Raynaud's phenomenon, immediate improvement can be achieved but the symptoms may return with time.

Endoscopic transthoracic sympathectomy: successful in hyperhidrosis but can the indications be extended?

Endoscopic transthoracic sympathectomy (ETS) has recently become established as a successful treatment for severe palmar and axillary hyperhidrosis. In this unit the indications for ETS have been broadened to include patients with Raynaud's syndrome and critical upper limb ischaemia and this paper is primarily concerned with analysing outcome in relation to the indication for operation. In all, 68 operations have been attempted in 40 patients and complete follow-up details are available on 62 treated limbs. One operation was a technical failure because of an obliterated pleural cavity. In the hyperhidrosis group (n = 28), all the affected areas showed symptomatic improvement at a median follow-up of 17 months. In the Raynaud's group (n = 30), 28 limbs (93%) were improved to some degree at the time of discharge, but at a median follow-up of 18 months only 15 limbs (50%) remained symtomatically improved to some degree. The four upper limbs treated for critical ischaemia were improved by ETS and no amputations were necessary. Significant postoperative chest pain was noted by nine patients (23%). There were three postoperative pneumothoraces, two intercostobrachial neuralgias and one transient Horner's syndrome. The cosmetic result was reported as excellent or good by 97% of patients. As with other forms of surgical thoracic sympathectomy, excellent early results are not maintained in the longer term when ETS is used to treat Raynaud's syndrome. Nevertheless, the greater simplicity and lower morbidity of the endoscopic method suggest that it can be offered to Raynaud's sufferers with greater impunity than open sympathectomies.

Sympathetic ganglion blockade for the management of hyperhidrosis

We present three patients with severe primary hyperhidrosis, refractory to conservative medical treatment, who were successfully managed with sympathetic ganglion blockade with ethanol. We also summarize 10 patients with hyperhidrosis who underwent sympathetic ganglion blockade in the past 2 years. This closed percutaneous method offers the patients considerably less discomfort and less stress with minimal morbidity and has a efficacy similar to that of surgical sympathectomy, which has previously been the only effective and permanent therapy for severe primary hyperhidrosis. It is concluded that chemical sympathectomy is an effective and useful method for treating severe hyperhidrosis which has advantages over surgical sympathectomy.

Craniofacial hyperhidrosis treated with video endoscopic sympathectomy

Craniofacial hyperhidrosis as well as palmar hyperhidrosis is an abnormal state of local excessive sweating of unclear etiology. The hyperhidrosis may be isolated in the craniofacial region or associated with palmar hyperhidrosis. The patient's face is so wet with sweat that their daily activities are often seriously disturbed. To the best of our knowledge, there has been no satisfactory medical therapy, nor any effective surgical treatment reported in the literature. In 1991, we started to treat a patient with such distress using endoscopic ablation of the sympathetic T2 segment, because we mastered the technique after treating a large series of palmar hyperhidrosis patients. Furthermore, we were impressed by concomitant reduction of craniofacial sweating after T2-3 sympathectomy resulting from the relatively different domination of sympathetic supply between the eye and face. It appears possible to relieve excessive sweating of the head and face, without producing ptosis or miosis by ablation of the T2 segment. During the past 2 years, 7 patients with severe craniofacial hyperhidrosis have been successfully treated with the method and all obtained a satisfactory result. No complete Horner's syndrome has been produced except in one patient, who showed a mild and transient left eye ptosis, in whom coagulation of the sympathetic trunk higher than the T2 segment was performed. Intraoperative monitoring of forehead skin perfusion and observation of the change of pupillary size is emphasized during the lesion making. The longest postoperative follow-up was 2 years, with a mean follow-up of 12.4 months.(ABSTRACT TRUNCATED AT 250 WORDS)