Long-term outcomes after endothoracic sympathetic block at the T4 ganglion for upper limb hyperhidrosis

Endoscopic thoracic sympathectomy for primary focal hyperhidrosis: impact on psycho-social symptomatology and psychotropic medication use

OBJECTIVES

The tendency for patients with primary focal hyperhidrosis (PFH), characterized by excessive sweating, to experience psycho-social deficits is well documented. In addition, although endoscopic thoracic sympathectomy (ETS) effectively corrects PFH, its role in the psycho-social management of these patients remains unclear. Here, we examined changes in psychiatric symptomatology and psychotropic medication usage in PFH patients following ETS.

METHODS

In total, 106 PFH patients underwent ETS and were compared against 213 matched controls. Information on psychiatric diagnosis and prescription was obtained through a retrospective chart review. Prospectively, PFH patients completed Hyperhidrosis Impact Questionnaires, Leibowitz Social Anxiety Scales and Center for Epidemiological Studies Depression Scales to evaluate pre- and postoperative quality-of-life and psycho-social impairment.

RESULTS

A significantly greater proportion of PFH patients had been prescribed psychotropic medication (37.7%) compared to controls (14.1%) despite no differences in the proportion of psychiatric diagnoses. Following ETS, 52.5% of the PFH patients who were using psychotropic medications reduced their prescription regimen, compared to only 10% of control patients (P < 0.01). Additionally, scores improved dramatically in each Hyperhidrosis Impact Questionnaires category, and in both the Leibowitz Social Anxiety Scales and Center for Epidemiological Studies Depression Scales (P < 0.01).

CONCLUSIONS

We demonstrate that in over half of PFH patients, psychotropic medication usage was discontinued after ETS, which is consistent with our findings on postoperative improvements in Hyperhidrosis Impact Questionnaires, Leibowitz Social Anxiety Scales and Center for Epidemiological Studies Depression Scales scores. Furthermore, our findings suggest that a considerable proportion of PFH patients who experience psychopathology may be doing so secondary to excessive sweating. Thus, improved awareness or recognition of these associations in the diagnosis and management of PFH patients is warranted.

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.

Optimal targeting of sympathetic chain levels for treatment of palmar hyperhidrosis: an updated systematic review

BACKGROUND

Palmar hyperhidrosis involves excessive sweating of the palms, with no known etiology. Endoscopic thoracic sympathectomy (ETS) is a safe and effective treatment for palmar hyperhidrosis, but compensatory hyperhidrosis is a common complication after ETS, leading to reduced patient satisfaction and postoperative quality of life. However, the appropriate level of the sympathetic chain to target with ETS to achieve maximum efficacy and reduce the risk of compensatory hyperhidrosis (CH) is controversial. In this systemic review, we investigated the appropriate level of sympathectomy for palmar hyperhidrosis.

METHODS

PRISMA guidelines were implemented to complete a systematic review. We performed a computerized systematic literature search using PubMed and EMBASE from January 1990 to July 2016. We chose the Cochrane Collaboration's tool and the methodological index for non-randomized studies tool for examining study bias.

RESULTS

A total of 4075 citations were identified, of which 91 were eligible for inclusion, including 68 observational studies and 23 comparative trials. In observational studies, sympathectomies showed similar efficacies for curing PH at different levels. However, T2-free groups (i.e., at levels T3, T4, or T3-T4 combined) could render a lower risk of Horner's syndrome (0 vs. 1.21 ± 0.49%, p = 0.036) and CH (28.75 ± 7.25 vs. 57.46 ± 3.86, p = 0.002) compared with T2 involved. In comparative trials, there were 12 studies describing the comparison between T2-free ETS and T2 involved, and 9 of 12 (75%) showed T2-free ETS could reduce the incidence of CH. Overall, lowering the level and limiting the extent of sympathectomy could reduce the incidence of complications.

CONCLUSIONS

Cumulative data from more than 13,000 patients suggest that ETS is a safe, effective, and reproducible procedure with a high degree of patient satisfaction. Currently available evidence suggests that T2-free ETS may reduce the incidence of compensatory hyperhidrosis without compromising success rates and safety.

Targeted stellate decentralization: Implications for sympathetic control of ventricular electrophysiology

BACKGROUND

Selective bilateral cervicothoracic sympathectomy has proven to be effective for managing ventricular arrhythmias in the setting of structural heart disease. In the procedure currently used, the caudal portions of both stellate ganglia along with thoracic chain ganglia down to T4 ganglia are removed.

OBJECTIVE

The purpose of this study was to define the relative contributions of the T1-T2 and T3-T4 paravertebral ganglia in modulating ventricular electrical function.

METHODS

In anesthetized vagotomized porcine subjects (n = 8), the heart was exposed via sternotomy along with right and left paravertebral sympathetic ganglia to the T4 level. A 56-electrode epicardial sock was placed over both ventricles to assess epicardial activation-recovery intervals (ARIs) in response to individually stimulating right and left stellate vs T3 paravertebral ganglia. Responses to T3 stimuli were repeated after surgical removal of the caudal portions of stellate ganglia and T2 bilaterally.

RESULTS

In intact preparations, stellate ganglion vs T3 stimuli (4 Hz, 4-ms duration) were titrated to produce equivalent decreases in global ventricular ARIs (right side: 85 ± 6 ms vs 55 ± 10 ms; left side: 24 ± 3 ms vs 17 ± 7 ms). Threshold of stimulus intensity applied to T3 ganglia to achieve threshold was 3 times that of T1 threshold. ARIs in unstimulated states were unaffected by bilateral stellate-T2 ganglion removal. After acute decentralization, T3 stimulation failed to change ARIs.

CONCLUSION

Preganglionic sympathetic efferents arising from the T1-T4 spinal cord that project to the heart transit through stellate ganglia via the paravertebral chain. Thus, T1-T2 surgical excision is sufficient to functionally interrupt central control of peripheral sympathetic efferent activity.

Thoracic sympathectomy: a review of current indications

BACKGROUND

Thoracic sympathetic ablation was introduced over a century ago. While some of the early indications have become obsolete, new ones have emerged. Sympathetic ablation is being still performed for some odd indications thus prompting the present study, which reviews the evidence base for current practice.

METHODS

The literature was reviewed using the PubMed/Medline Database, and pertinent articles regarding the indications for thoracic sympathectomy were retrieved and evaluated. Old, historical articles were also reviewed as required.

RESULTS AND CONCLUSIONS

Currently, thoracic sympathetic ablation is indicated mainly for primary hyperhidrosis, especially affecting the palm, and to a lesser degree, axilla and face, and for facial blushing. Despite modern pharmaceutical, endovascular and surgical treatments, sympathetic ablation has still a place in the treatment of very selected cases of angina, arrhythmias and cardiomyopathy. Thoracic sympathetic ablation is indicated in several painful conditions: the early stages of complex regional pain syndrome, erythromelalgia, and some pancreatic and other painful abdominal pathologies. Although ischaemia was historically the major indication for sympathetic ablation, its use has declined to a few selected cases of thromboangiitis obliterans (Buerger's disease), microemboli, primary Raynaud's phenomenon and Raynaud's phenomenon secondary to collagen diseases, paraneoplastic syndrome, frostbite and vibration syndrome. Thoracic sympathetic ablation for hypertension is obsolete, and direct endovascular renal sympathectomy still requires adequate clinical trials. There are rare publications of sympathetic ablation for primary phobias, but there is no scientific basis to support sympathetic surgery for any psychiatric indication.

Quality of life after sympathetic surgery at the T4 ganglion for primary hyperhidrosis: clip application versus diathermic cut

INTRODUCTION

Limited procedures at the T4 ganglion show low rates of compensatory sweating (CS). The aim of the study was to compare endoscopic sympathetic block (ESB) via clip application with endothoracic sympathicotomy (ETS) via diathermy with special regard on patients' quality of life (Qol).

PATIENTS AND METHODS

Treatment success, side effects and patient satisfaction were evaluated in a prospectively gathered database of a tertiary-care referral hospital. Two disease-specific Qol questionnaires were used (Keller, Milanez de Campos).

RESULTS

406 operations were performed in 205 patients (ESB4 N = 114, ETS4 N = 91) with a median follow-up of 12 months. Both procedures improved Qol significantly (P < 0.001) and the degree of improvement was equal in both groups. Palmar and axillary HH were ameliorated after both procedures (P < 0.001). Accordingly, plantar HH decreased after ESB4 (P = 0.002), while remaining unaltered after ETS4. Nineteen patients (9.3%) reported CS and 10 patients (4.9%) judged it as "disturbing". Nine of the latter belonged to the ETS4 group compared to one ESB patient (P = 0.015). Patients developed higher rates of plantar CS after ETS4 compared to ESB4 (P = 0.006). Five patients (2.4%) from both cohorts reported persistence of axillary HH. Recurrence of axillary symptoms was found in 5 ESB4 patients. Satisfaction rates did not differ significantly.

CONCLUSION

Patients' Qol and satisfaction rates are similar in both treatment groups for upper limb HH. Outcome and recurrence rates speak in the favor of ETS4, severity of CS and potential reversibility argue for ESB4.

Sympathetic block by metal clips may be a reversible operation

OBJECTIVES

Thoracoscopic sympathectomy is now used routinely to treat patients with disabling primary hyperhidrosis or facial blushing. Published results are excellent, but side effects, such as compensatory sweating, are also very frequent. The surgical techniques used and the levels of targeting the sympathetic chain vary tremendously. Most surgeons transect or resect the sympathetic chain, but application of a metal clip that blocks transmission of nerve impulses in the sympathetic chain is used increasingly worldwide. This approach offers potential reversibility if patients regret surgery, but the question of reversibility remains controversial. Two recent experimental studies found severe histological signs of nerve damage 4-6 weeks after clip removal, but they only used conventional histopathological staining methods.

METHODS

Thoracoscopic clipping of the sympathetic trunk was performed in adult sheep, and the clip was removed thoracoscopically after 7 days. Following another 4 weeks (n = 6) or 12 weeks (n = 3), the sympathetic trunks were harvested and analysed by conventional and specific nerve tissue immunohistochemical stains (S100, neurofilament protein and synaptophysin). The contralateral sympathetic chains were used as controls.

RESULTS

Conventional and immunohistochemical stains demonstrated severe signs of neural damage on the operated side 4 weeks after clip removal. After 12 weeks, these changes had decreased markedly and conventional histology had almost normalized.

CONCLUSIONS

Conventional and immunohistochemical stains confirmed that application of metal clips to the sympathetic chain caused severe histological damage in the sympathetic trunk that remained visible 4 weeks after clip removal. However, after 12 weeks, these signs of damage had clearly decreased, which suggests in theory that application of metal clips to the sympathetic chain is a reversible procedure if only the observation period is prolonged. Further studies with longer periods between application and removal as well as investigations of nerve conduction should be encouraged, because we do not know whether histological reversibility at cellular level translates into physiological reversibility and possible correlation of nerve trauma with the duration of the applied clip.