Surgical implications of upper thoracic independent sympathetic pathways

Reoperation for Essential Hyperhidrosis

Palmar hyperhidrosis has a recurrence rate of 0% to 5% after thoracic sympathectomy. From January 1992 to October 1997, thoracic sympathectomy was performed by video-assisted thoracoscopic surgery for hyperhidrosis in 490 patients of whom 5 (2 male and 3 female with a mean age of 20 years) experienced recurrent hyperhidrosis in the early (< 7 days) or late (up to 6 months) postoperative period. All patients had moderate to severe pleural adhesions in the previous sympathectomy sites but no operative complications or crossover to thoracotomy occurred. Surgery resulted in satisfactory outcomes showing that video-assisted thoracoscopic sympathectomy was effective in treating recurrent hyperhidrosis. Prevention of recurrence requires the identification and resection of the second thoracic sympathetic ganglion as well as the Kuntz fibers.

Thoracoscopic and anatomic landmarks of Kuntz's nerve: implications for sympathetic surgery

BACKGROUND

Kuntz's nerves (KN) have been blamed for surgical failures of endothoracic sympathectomy. The prevalence of these fibers, however, varies between the surgical (about 10%) and anatomic literature (about 80%). This clinically orientated cadaveric study was conducted to explain this discrepancy, to reveal possible reasons for the low thoracoscopic detection rate, and to define anatomic structures as possible landmarks of KNs.

METHODS

Video-assisted thoracoscopy was performed in 33 thoracic cavities of fresh human cadavers within 48 hours postmortem, followed by anatomic dissection of the first intercostal space. Kuntz's nerves and concomitant blood vessels were of special interest. Statistical analysis included frequencies and chi(2) tests.

RESULTS

Kuntz's nerves were identified in 12.1% by thoracoscopy, whereas anatomic dissection revealed KNs in 66.7% (p = 0.003). Subpleural veins (mean diameter, 2.2 +/- 0.9 mm) parallel to KNs were found in 81.8%. No collateral arteries were identified. Diameters of KNs were 1.4 +/- 0.7 mm; distances between the first thoracic ganglion and the middle of KNs were 9.7 +/- 3.0 mm. Thoracoscopic recognition of these Kuntz veins was higher than that of KNs (62.5% vs 18.2%, p < 0.005).

CONCLUSIONS

The low thoracoscopic detection rate of KNs may be due to the low color contrast of these small fibers. They have, however, most frequently concomitant subpleural veins that are easier to detect. These veins may serve as orientation landmarks of KNs and thus contribute to a more complete denervation improving the outcome of thoracoscopic sympathectomies.

The treatment of primary palmar hyperhidrosis: a review

Primary palmar hyperhidrosis (HH) is a pathological condition of overperspiration caused by excessive secretion of the eccrine sweat glands, the etiology of which is unknown. This disorder affects a small but significant proportion of the young population all over the world. Neither systemic nor topical drugs have been found to satisfactorily alleviate the symptoms. Although the topical injection of botulinum has recently been reported to reduce the amount of local perspiration, long-term results are required before a definitive evaluation of this method can be made. Hypnosis, psychotherapy, and biofeedback have been beneficial in a limited-number of cases. While radiation achieves atrophy of the sweat glands, its detrimental effects prohibit its use. Iontophoresis has attained some satisfactory results but it has not been assessed long term. Percutaneous computed tomography-guided phenol sympathicolysis achieves excellent immediate results, but its long-term failure rate is prohibitive. Furthermore, percutaneous radiofrequency sympathicolysis may be an effective procedure, but its long-term results are not superior to surgical sympathectomy. On the other hand, surgical upper dorsal (T2-T3) sympathectomy achieves excellent long-term results and the thoracoscopic approach has supplanted the open procedures. Despite some sequelae, mainly in the form of neuralgia and compensatory sweating which cannot be predicted and may be distressing, surgical sympathectomy remains the best treatment for palmar hyperhidrosis.

Upper thoracic sympathectomy for primary palmar hyperhidrosis: long-term follow-up

Primary palmar hyperhidrosis is a functionally and socially disabling condition. Upper thoracic sympathectomy is the best curative treatment. Several surgical approaches have been suggested and, recently, less invasive techniques have been communicated. To evaluate which method is the best, the short- and particularly the long-term results must be compared. A series is presented of 170 upper thoracic sympathectomies by the supraclavicular approach performed on 85 patients with palmar hyperhidrosis. Follow-up for a mean of 8.3 years was obtained on 124 operated limbs. The immediate failure rate for relief from hyperhidrosis was 2.4 per cent and hyperhidrosis recurred in another 4.1 per cent of limbs after a period of between 2 and 18 months. Thirteen per cent of patients were dissatisfied with the results of operation, one because of persisting vasomotor rhinitis, two because of Horner's syndrome and five because of persisting or recurrent hyperhidrosis. Satisfactory results in approximately 87 per cent of cases make the operation rewarding. This outcome should be compared with the long-term results of other methods, such as percutaneous phenol injection and the transthoracoscopic approach, when such data are compiled and published.

Extended thoracoscopic T2-sympathectomy in treatment of hyperhidrosis: experience with 130 consecutive cases

A new method of thoracoscopic T2-sympathectomy mentioned in a previous report was used on 36 cases of hyperhidrosis at Tainan Municipal Hospital in Taiwan between October 1, 1989 and July 31, 1990. To reduce the possibility of incomplete resection of sympathetic nerve tracts, including ganglions and their regeneration, the method was modified on August 1, 1990. Thereafter, routine total removal of T2 and T3 sympathetic ganglions, as well as wide lateral incisions of the pleura on the second, third, and fourth rib beds were performed for treatment of hyperhidrosis. This newly modified method, "extended thoracoscopic T2-sympathectomy," can be performed easily by thoracoscopic approach in the treatment of hyperhidrosis palmaris. From August 1, 1990 to May 31, 1991, 130 consecutive cases of hyperhidrosis (56 males and 74 females) ranging in age from 8 to 51 years underwent extended thoracoscopic T2-sympathectomy. In addition to a nearly 100% cure rate of hyperhidrosis palmaris, significant saving in operative time and hospital stay were achieved. High simultaneous cure rate (70.6%) and subjective improvement (17.4%) of excessive sweating of feet (hyperhidrosis plantaris) were also noted in the 109 cases followed up, and complications were minor. Extended thoracoscopic T2-sympathectomy is not only a time-saving method but also a very simple and effective method in the treatment of hyperhidrosis. It is worthy of being propagated worldwide.

An analysis of the sympathetic trunk and rami in the cervical and upper thoracic regions in man

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