Factors affecting outcome following endoscopic thoracic sympathectomy

Interventions for hyperhidrosis in secondary care: a systematic review and value-of-information analysis

BACKGROUND

Hyperhidrosis is uncontrollable excessive sweating that occurs at rest, regardless of temperature. The symptoms of hyperhidrosis can significantly affect quality of life. The management of hyperhidrosis is uncertain and variable.

OBJECTIVE

To establish the expected value of undertaking additional research to determine the most effective interventions for the management of refractory primary hyperhidrosis in secondary care.

METHODS

A systematic review and economic model, including a value-of-information (VOI) analysis. Treatments to be prescribed by dermatologists and minor surgical treatments for hyperhidrosis of the hands, feet and axillae were reviewed; as endoscopic thoracic sympathectomy (ETS) is incontestably an end-of-line treatment, it was not reviewed further. Fifteen databases (e.g. CENTRAL, PubMed and PsycINFO), conference proceedings and trial registers were searched from inception to July 2016. Systematic review methods were followed. Pairwise meta-analyses were conducted for comparisons between botulinum toxin (BTX) injections and placebo for axillary hyperhidrosis, but otherwise, owing to evidence limitations, data were synthesised narratively. A decision-analytic model assessed the cost-effectiveness and VOI of five treatments (iontophoresis, medication, BTX, curettage, ETS) in 64 different sequences for axillary hyperhidrosis only.

RESULTS AND CONCLUSIONS

Fifty studies were included in the effectiveness review: 32 randomised controlled trials (RCTs), 17 non-RCTs and one large prospective case series. Most studies were small, rated as having a high risk of bias and poorly reported. The interventions assessed in the review were iontophoresis, BTX, anticholinergic medications, curettage and newer energy-based technologies that damage the sweat gland (e.g. laser, microwave). There is moderate-quality evidence of a large statistically significant effect of BTX on axillary hyperhidrosis symptoms, compared with placebo. There was weak but consistent evidence for iontophoresis for palmar hyperhidrosis. Evidence for other interventions was of low or very low quality. For axillary hyperhidrosis cost-effectiveness results indicated that iontophoresis, BTX, medication, curettage and ETS was the most cost-effective sequence (probability 0.8), with an incremental cost-effectiveness ratio of £9304 per quality-adjusted life-year. Uncertainty associated with study bias was not reflected in the economic results. Patients and clinicians attending an end-of-project workshop were satisfied with the sequence of treatments for axillary hyperhidrosis identified as being cost-effective. All patient advisors considered that the Hyperhidrosis Quality of Life Index was superior to other tools commonly used in hyperhidrosis research for assessing quality of life.

LIMITATIONS

The evidence for the clinical effectiveness and safety of second-line treatments for primary hyperhidrosis is limited. This meant that there was insufficient evidence to draw conclusions for most interventions assessed and the cost-effectiveness analysis was restricted to hyperhidrosis of the axilla.

FUTURE WORK

Based on anecdotal evidence and inference from evidence for the axillae, participants agreed that a trial of BTX (with anaesthesia) compared with iontophoresis for palmar hyperhidrosis would be most useful. The VOI analysis indicates that further research into the effectiveness of existing medications might be worthwhile, but it is unclear that such trials are of clinical importance. Research that established a robust estimate of the annual incidence of axillary hyperhidrosis in the UK population would reduce the uncertainty in future VOI analyses.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015027803.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A retrospective review on minimally invasive technique via endoscopic thoracic sympathectomy (ETS) in the treatment of severe primary hyperhidrosis: Experiences from the National Heart Institute, Malaysia

Background: Hyperhidrosis is due to the hyperactive autonomic stimulation of the sweat glands in response to stress. Primary hyperhidrosis is a common yet psychologically disabling condition. This study will describe our experience in managing hyperhidrosis via endoscopic thoracic sympathectomy (ETS).

Methods: The information was obtained from the patient records from 1 ^st January 2011 until 31 ^st December 2016. Pertinent information was extracted and keyed into a study proforma.

Results:  150 patients were operated on but only 118 patients were included in this study. The mean age was 22.9±7.3 years. The majority (54.2%) had palmar-plantar hyperhidrosis and 39.8% had associated axillary hyperhidrosis. Excision of the sympathetic nerve chain and ganglia were the main surgical technique with the majority (55.9%) at T2-T3 level. Mean ETS procedure time was 46.6±14.29 minutes with no conversion. Surgical complications were minimal and no Horner’s Syndrome reported. Mean hospital stay was 3.5±1.05 days. The majority of patients (67.8%) had only one follow-up and only half of the study sample (58.5%) complained mild to moderate degree of compensatory sweating, even though the long-term resolution is yet to be determined by another study. Following ETS, 98.3% of patients had instant relief and resolved their palmar hyperhidrosis. Predictors of CS were sympathectomy level and follow-up. The odds of reporting CS was 2.87 times in patients undergoing ETS at the T2-T3 level compared to those undergoing ETS at the T2-T4 level. The odds of reporting CS was 13.56 times in patients having more than one follow-up compared to those having only one follow-up.

Conclusion: We conclude that ETS is a safe, effective and aesthetically remarkable procedure for the treatment of primary hyperhidrosis  with only half of the patients developing mild to moderate degree of CS. Significant predictors of CS were sympathectomy level during ETS and frequency of follow-up after ETS.

Management of Plantar Hyperhidrosis with Endoscopic Lumbar Sympathectomy

Primary plantar hyperhidrosis is defined as excessive secretion of the sweat glands of the feet and may lead to significant limitations in private and professional lifestyle and reduction of health-related quality of life. Conservative therapy measures usually fail to provide sufficient relieve of symptoms and do not allow long-lasting elimination of hyperhidrosis. Endoscopic lumbar sympathectomy appears to be a safe and effective procedure for eliminating excessive sweating of the feet and improves quality of life of patients with severe plantar hyperhidrosis.

Influence of thoracoscopic sympathectomy on tendency to cry - case-controlled study

Introduction

Primary hyperhidrosis (PHH) is a disease that is mainly characterized by increased palmar and plantar sweating that significantly affects the everyday functioning. It is not clear to what extent this surgical intervention has an effect on one's further emotional functioning.

Aim

To evaluate the impact of endoscopic thoracic sympathectomy (ETS) on crying tendency in PHH patients.

Material and methods

Eighty-six patients qualified for ETS due to PHH took part in the study. All patients completed the Adult Crying Inventory (ACI) and the Functional Assessment of Chronic Illness Therapy (FACIT) questionnaires before and 3 months after sympathectomy. The ACI questionnaire was additionally completed by a group of 60 volunteers.

Results

In females, the number of crying episodes increased after ETS, though it was still lower than the number observed in the control group (1.19 vs. 2.36 vs. 3.83; p < 0.05). In males the number of crying episodes dropped insignificantly to the number observed in the control group (0.87 vs. 0.27 vs. 0.14; p = NS). The tendency to cry in females decreased compared to the level prior to surgery, but it was lower than the level observed in the control group (respectively, 4.5 vs. 3.5 vs. 5.63; p < 0.05). In males the differences were not statistically significant (1.03 vs. 1.5 vs. 1.77; p = NS). There was no impact of emotional status on crying, either before or after the treatment.

Conclusions

Endoscopic thoracic sympathectomy decreases the subjective tendency to cry though it increases the number of crying episodes in women, but does not change crying behaviours in men.

Is age group a predictive factor for satisfaction among patients undergoing sympathectomy to treat hyperhidrosis?

OBJECTIVE: Video-assisted thoracic sympathectomy is currently the procedure of choice for the definitive treatment of primary hyperhidrosis, because it is an effective, safe, and minimally invasive method. In the search for better quality of life indexes, all researchers look for predictive factors indicating better surgical outcomes. Failure in the primary treatment, postoperative compensatory hyperhidrosis, body mass index over 25, level of resection of the sympathetic chain, and extent of resection are some of the factors that may negatively influence the results. The objective of this study was to compare, according to the age group, the quality of life after bilateral thoracic sympathectomy for treatment of primary hyperhidrosis in a cohort of 1,644 patients. METHODS: From February 2000 to October 2008, data were collected from 1,644 patients with palmar (71%) or axillary (29%) hyperhidrosis who underwent video-assisted thoracic sympathectomy. The patients were divided into three groups according to their ages. The first group consisted of patients up to 17 years-old, the second from 18 to 30 years-old, and the third of over 30 years-old. All patients had a body mass index of less than 25. RESULTS: In the evaluation 30 days after surgery, improvement of the quality of life in the three groups was observed. There was no significant difference between the age groups. In the present study, 91.9% of the patients presented compensatory hyperhidrosis, with no difference between the age groups. CONCLUSIONS: Patients with primary hyperhidrosis experience quality of life improvement after thoracic sympathectomy regardless of their age.

The effect of thoracoscopic sympathicotomy at the fourth rib (r4) for the treatment of palmar and axillary hyperhidrosis

Background

Video-assisted thoracic sympathicotomy plays an important for the treatment of essential hyperhidrosis. Patients are usually satisfied with the surgical outcome at the early post-operative period, but suffer recurrence and compensatory sweating in the late post-operative period. There are many sympathicotomy methods to minimize recurrence and compensatory sweating. We compared the outcome of sympathicotomy methods above the third rib (R3) and the fourth rib (R4) with regards to symptoms, satisfaction, recurrence, and compensatory palmar and axillary hyperhydrosis.

Materials and Methods

From January 1999 to April 2009, 39 cases of thoracoscopic sympathicotomy at the third rib (R3), and 94 cases of thoracoscopic sympathicotomy at the fourth rib (R4) for palmar and axillary hyperhidrosis were compared for early and late post-operative satisfaction, compensatory sweating and recurrence.

Results

There was no sex or age difference between groups. Early satisfaction was 94.9% and 98.9% in the R3 group and R4 group, respectively. There was no difference in early satisfaction (94.9% in R3 and 98.9% in R4), late satisfaction (84.6% in R3 and 89.4% in R4), or recurrence (17.9% in R3 and 17.0% in R4) between groups. There was significant difference in compensatory sweating (71.8% in R3 and 33% in R4, p=0.002).

Conclusion

R4 sympathicotomy demonstrated superior efficacy in the treatment of compensatory sweating compared to R3 in palmar and/or axillary hyperhidrosis.

Treatment of bromhidrosis with a glycine-soja sterocomplex topical product

AIMS

Bromhidrosis is a common problem with a severe negative impact on the patient's social and emotional life. The objective of this open-label study was to evaluate the efficacy and safety of a local product with the main active ingredient of glycine-soja sterocomplex in the treatment of local bromhidrosis.

PATIENTS/METHODS

Eighteen patients with axillary bromhidrosis and eight patients with bromhidrosis of the genital area were included. Bromhidrosis was evaluated through a sniff test of a worn garment on a four-point scale. Patients applied a glycine-soja sterocomplex topical agent twice daily on the affected areas for 15 days and bromhidrosis was evaluated again.

RESULTS

Subjective mean level of bromhidrosis at baseline was 3.50 ± 0.50 and after treatment 1.53 ± 0.51. Mean impact on quality of life at baseline was 3.30 ± 0.48 and after treatment 1.30 ± 0.49. Investigators objective evaluation revealed an improvement in intensity of odor from 3.23 ± 0.83 to 1.53 ± 0.53 and in acceptability of odor from 3.1 ± 1.01 to 1.65 ± 0.76.

CONCLUSIONS

The glycine-soja sterocomplex topical agent shows encouraging improvement on both the intensity and quality of odor in patients with bromhidrosis and has a profound improvement on the patients' quality of life without any side effects.

Endoscopic lumbar sympathectomy for plantar hyperhidrosis

Background

The aim of this study was to evaluate the results of endoscopic lumbar sympathectomy for plantar hyperhidrosis.

Methods

A total of 178 endoscopic resections of the lower sympathetic lumbar trunk were carried out in 90 patients (59 men, 31 women) with severe plantar hyperhidrosis. The clinical results, including morbidity and satisfaction rates, were evaluated. Follow-up examination was carried out for all patients after a mean follow-up of 24 (range 3–45) months.

Results

All procedures were carried out endoscopically. There were no deaths and only three patients had a postoperative complication. All patients had evidence of postoperative sympathetic denervation of the feet. In 87 patients (97 per cent) hyperhidrosis was eliminated, but in three (3 per cent) it recurred. Compensatory sweating occurred in 40 patients (44 per cent), postsympathectomy neuralgia in 38 (42 per cent) and one man suffered temporary loss of ejaculation. A total of 86 patients (96 per cent) were very, or partly, satisfied with the result, and 83 (92 per cent) would have the procedure repeated if required.

Conclusion

Endoscopic lumbar sympathectomy was a safe and effective option for patients with severe plantar hyperhidrosis.

Influence of T3 or T4 sympathicotomy for palmar hyperhidrosis

BACKGROUND

This retrospective study aimed to compare the efficacy of video-assisted thoracoscopic sympathicotomy at the T3 or T4 level in the treatment of palmar hyperhidrosis.

METHODS

Patients were operated on for palmar hyperhidrosis from April 2004 to December 2007, and classified as the T3 (n = 56) or T4 (n = 63) sympathicotomy group.

RESULTS

The rate of dryness and compensatory hyperhidrosis (CH) was significantly lower in the T4 sympathicotomy group than the T3 group (P < .01). Satisfaction rate, recurrence, and improvement of plantar sweating were of no statistical significance in either group.

CONCLUSIONS

Although both sympathicotomies were effective, safe, and minimally invasive methods for the treatment of palmar hyperhidrosis, T4 appeared to be a more optimal technique with less CH.

Primary palmoplantar hyperhidrosis and thoracoscopic sympathectomy: a new objective assessment method

BACKGROUND

This study was conducted to establish an objective approach to evaluate symptoms and sweat production in patients with primary palmoplantar hyperhidrosis (PPH) and assess their response to bilateral thoracoscopic sympathectomy (BTS).

METHODS

We conducted two institutional review board-approved studies. We performed a one-time evaluation of healthy volunteers (controls) with three questionnaires (Hyperhidrosis Disease Severity Scale, Dermatology Life Quality Index, and Short Form-36) and measurement of transepidermal water loss (TEWL; g/m(2)/h). We evaluated PPH patients with these same tools before and 1 month after BTS and compared them with controls.

RESULTS

We evaluated 35 controls (mean age, 23.0 +/- 3.3 years) and 45 PPH patients (mean age, 26.5 +/- 12.3 years); 18 PPH patients underwent BTS and the 1-month postoperative evaluation. Hyperhidrosis Disease Severity Scale and Dermatology Life Quality Index scores were higher in PPH patients than in controls (p < 0.0001), but normalized after BTS. Short Form-36 scale scores were lower in PPH patients than in controls (p < 0.05), but improved significantly after BTS. Compared with controls, preoperative TEWL values were significantly higher in PPH patients (palmar: 142.7 +/- 43.6 PPH vs 115.8 +/- 48.7 controls, p = 0.011; plantar: 87.5 +/- 28.8 PPH vs 57.7 +/- 24.7 controls, p < 0.0001). After BTS, palmar TEWL values were significantly lower (49.1 +/- 29.8, p < 0.0001). Plantar TEWL did not change significantly (77.6 +/- 46.6, p = 0.52).

CONCLUSIONS

PPH patients should be objectively evaluated with standardized quality of life measures and TEWL measurements before and after treatment. We believe that this objective practical approach provides a benchmark for clinical practice and research.

Evidence-based review of the surgical management of hyperhidrosis

The great majority of the currently available evidence supporting sympathectomy for primary hyperhidrosis is observational, coming from a variety of prospective and restrospective clinical series as well as comparative studies. A cumulative experience in over 6000 patients suggests that ETS is a safe, reproducible, and effective procedure, and most patients are satisfied with the results of the surgery. The currently available experimental data comes from clinical trials that compared alternative levels of sympathetic chain disruption; these trials speak only to the relative merits of one surgical technique over another and do not provide an assessment of the overall impact of surgery in the general population of patients with primary hyperhidrosis. Furthermore, it is difficult to compare series and generalizability is compromised by a lack of uniform definitions and measures at both the exposure and outcome levels. There is marked heterogeneity with respect to study population and entry criteria, with significant variability of site and severity of excess sweating as well as the degree of preoperative conservative management of hyperhidrosis before surgical referral. Also the operative approach varies widely among studies, and the optimal procedure remains elusive: unilateral versus staged nonsimultaneous bilateral versus concomitant bilateral sympathectomy; ganglionic resection versus ablation using electrocoagulation or harmonic scalpel; clipping of the chain to maintain reversibility in the event of intolerable symptoms versus permanent disruption. In addition, the lack of uniform outcome measures makes these data difficult to interpret, and standardized metrics of surgical results are necessary, such as objective quantification of sweating by gravimetry or use of the SF-36 Health Survey Questionnaire as an estimate of patient quality of life. A multicenter, adequately powered, randomized controlled trial comparing surgical to medical management of hyperhidrosis is unlikely given the current enthusiasm for same-day thoracoscopic sympathectomy among surgeons, a largely positive literature replete with encouraging results, and well-informed hyperhidrosis patients who want to be cured of a socially debilitating illness. Future clinical trials in this area will likely compare surgical techniques. For such comparisons, procedures must be standardized and outcome measures validated for both symptoms of the disease and surgical complications. Finally, the studies must have large numbers of patients and adequate long-term follow-up if they are to detect differences in results among procedures with very high technical success rates.

Do children tolerate thoracoscopic sympathectomy better than adults?

Palmar hyperhidrosis (PHH) is fairly a common condition, which is treatable by thoracoscopic sympathectomy (TS). Compensatory sweating (CS) is a major side effect of TS. We compared the TS procedure's long-term success, patient's satisfaction and complications between children (< or =14 years of age) and adolescents and adults (> or =15 years of age). A chart review of the patients who had undergone TS at three medical centers (Hillel Yaffe, Soroka and Bnai-Zion) who could be contacted and agreed to reply to a detailed telephone questionnaire yielded 325 patients with a >24-month follow-up. There were 116 children and 209 adolescents and adults with a follow-up of 2-8 years. Most participants (96.3%) reported complete or reasonable symptomatic relief. The long-term postoperative satisfaction was high (84.5%), and significantly higher among children (92.2%) compared to adolescents and adults (80.7%) (P = 0.005). CS appeared within 6 months postoperatively in 81.8% of all the patients but significantly less in children (69.8%) compared to the others (88.5%; P < 0.001). CS increased with time in 12% of the participants, but decreased in 20.8% of the children versus 10.5% of the others (P = 0.034), usually within the first two postoperative years. The severity of the CS was also lower in children: it was absent or mild in 54.3% of the children versus 38.0% of the others, and moderate or severe in 45.7 versus 62%, respectively (P = 0.004). Fifty-one percent of the participants claimed that their quality of life decreased moderately or severely as a result of CS, but only one-third of them (7.9% children vs. 22.4% others, P = 0.001) would not have undergone the operation in retrospect. Thoracoscopic sympathectomy relieves PHH in most cases. Most patients prefer relief from PHH even at the cost of moderate or severe CS. The rate of CS and its severity is tolerated better by children, and their postoperative satisfaction is higher than that of adolescents and adults. Therefore, unless otherwise contraindicated, we recommend doing TS as early as possibly.