Hyperhidrosis and its surgical treatment

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.

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.

Physical enhancement of dermatologic drug delivery: iontophoresis and phonophoresis

Iontophoresis and phonophoresis are emerging technologies capable of enhancing drug penetration through the stratum corneum, the principal barrier to percutaneous absorption. With utilization of applied electric current or ultrasonic waves, respectively, iontophoresis and phonophoresis have shown efficacy in an increasing number of clinical applications. This article reviews the underlying principles, current status, and potential of iontophoresis and phonophoresis in dermatologic therapy.

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.

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.

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.

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

Primary palmar hyperhidrosis is part of a triad of palmar, plantar, and axillary hyperhidrosis of unknown etiology, affecting children, adolescents, and young adults. Sixty-seven children and young adolescents were operated on during a 10-year period. A total of 103 transaxillary upper thoracic sympathectomies (36 bilateral) were performed, with no mortality. The immediate postoperative course was uneventful in 90%; the other 10% had mostly minor problems. The average hospitalization period was 3 to 4 days. Total abolition of palmar sweating was achieved in all but two patients in whom some residual moisture remained. Long-term extreme satisfaction was reported by 64 of 67 patients (94%). One was moderately satisfied, and two were not satisfied because of excessive "compensatory" sweating elsewhere. Compensatory sweating of some degree was reported by 45% of patients but did not alter satisfaction. By further limiting ganglionectomy to just one ganglion (T2 or T3), compensatory sweating possibly may be reduced further. Early surgery for severe palmar hyperhidrosis will save a child many years of agony and social discomfort because all types of conservative therapy are ineffective and cause unnecessary delay. A limited transaxillary upper thoracic sympathectomy is presently the authors' preferred approach, although ablation via thoracoscopy should not be excluded as further experience is gained with this modality.

Palmar hyperhidrosis in children: treatment with video endoscopic laser sympathectomy

Palmar hyperhidrosis (PH) often starts in childhood and can be a disabling condition for a significant number of young children at the age they begin primary school. There are few reports regarding the surgical treatment of PH in children. The authors report on 40 PH patients under 16 years of age treated with video thoracoscopic laser sympathectomy; there has been substantial experience with this procedure for the treatment of adults with PH. A satisfactory result, with very low morbidity, was achieved for all 40 children. The surgical technique is described briefly. With the technique, the proper sympathetic segment is visualized in almost all cases and then definitely ablated with a fiberoptic low-power laser while under the aid of sympathetic monitoring. Consequently, an adequate sympathectomy warranting a long-lasting therapeutic effect can be achieved without the need of tissue diagnosis. No case required conversion to open sympathectomy. Neither injury to the lung nor bleeding was encountered. Horner's syndrome did not occur in any case. Bilateral sympathectomy was accomplished generally within 30 minutes. All patients were discharged after an overnight stay and are doing well with normal activities. The most frequent complication was compensatory hyperhidrosis, which was tolerable after reassurance. Based on the accumulated experience, it is justified to recommend early surgery, with this refined technique, in cases of severe PH in children.

Autonomic activities in hyperhidrosis patients before, during, and after endoscopic laser sympathectomy

Three hundred palmar hyperhidrosis (PH) patients have been treated with video endoscopic laser sympathectomy during the last 2 years. Monitoring the palmar skin perfusion (PSP) and palmar skin temperature (PST) has been used intraoperatively to aid the confirmation of the correct sympathetic segment for laser ablation. The preoperative and postoperative PSP and PST and sympathetic skin response (SSR) also have been measured to evaluate the therapeutic effect of this method. An apparent increase of PSP would occur intraoperatively after the interruption of the T2 sympathetic segment, and then a gradual elevation of PST would follow after the extirpation of the segment. A rise of PST of about 3 degrees C after laser ablation of the appropriate segment indicated sufficient denervation of the hand and predicted long-lasting relief of PH. Furthermore, both PSP and PST also significantly increased after the operation. The postoperative elevation of the PST (usually about 3 degrees C) is similar to that recorded during intraoperative monitoring. The amplitude and the latency of SSR in the palm and sole were recorded both before and after sympathectomy. A remarkable decrease of palmar SSR amplitude and its ratio was found postoperatively by comparing it with that of plantar SSR in the same patient. These autonomic activity changes have correlated well with the postoperative satisfaction of the patients. Based on our study, the anatomic identification confirmed by the sympathetic monitorings has proved essential to achieve a definite and adequate sympathectomy leading to a satisfactory resolution of PH without the need of a tissue diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Video-assisted endoscopic thoracic ganglionectomy

Sympathetic nerve disorders of the upper extremities can be treated by neurosurgeons using upper thoracic sympathectomy via a posterior approach. Descriptions have been published of alternative endoscopic procedures involving thermocoagulation, laser coagulation, or nonvideo-assisted ganglionectomy using equipment not widely available, with low morbidity and excellent results. The authors describe the use of an endoscopic approach to the thoracic sympathetic ganglia with systems designed for laparoscopic cholecystectomy. Thoracic ganglionectomy is reported in 22 patients with primary palmar hyperhidrosis and eight patients with reflex sympathetic dystrophy. The patients underwent double-lumen endotracheal intubation, after which 11- and 5.5-mm trocars were introduced into the chest cavity. Pneumothorax was produced with CO2 insufflation. Fiberoptic closed-circuit television was used to visualize the structures to be dissected. The parietal pleura over the heads of the first and second ribs was excised using 5-mm blunt and sharp insulated coagulating microscissors. The stellate and upper thoracic ganglia were clearly identified and dissected. The T-2 and T-3 ganglia were grasped with forceps and excised. A No. 16 French chest tube was introduced through a trocar, placed under water seal after the lungs were reinflated, and removed in the recovery room. The average hospital stay was 15.4 hours. There were no intraoperative complications. The average operating time was 30 minutes per side. Five patients had mild pleuritic pain which resolved within 2 weeks after surgery. Six (75%) of the eight patients with reflex sympathetic dystrophy had complete or partial relief of their symptoms (average follow-up period 5 months), and all patients had complete relief of hyperhidrosis (average follow-up period 8 months). Endoscopic ganglionectomy requires readily available and easily used instrumentation and provides a well-tolerated, cost-effective alternative to posterior thoracic sympathectomy for primary palmar hyperhidrosis and reflex sympathetic dystrophy.

Endoscopic electrocautery of the thoracic sympathetic chain. A minimally invasive way to treat palmar hyperhidrosis

Four hundred and fifty patients with palmar hyperhidrosis have undergone endoscopic thoracic sympathetic electrocautery since 1987 in our department. The procedure requires only minor modifications of standard laparoscopic and urological equipment. The median operating time for a bilateral procedure was 31 minutes (15-120), hospital stay was 1 day postoperatively (1-8), and patients returned to work within 4 (1-40) days. Complications in the whole material were few and mild, pneumothorax (n = 2), haemothorax (n = 1), and Horner's syndrome (n = 1). Five patients required reoperation (four because of primary failure to destroy the nerve and one for recurrent symptoms). The first consecutive 130 of these patients have been followed up by a questionnaire. At follow-up (median 196 days after operation, range 35-1419) all patients but three, who are awaiting reoperation were satisfied with the result. The discomfort and side effects of the operation were in most cases mild and short. This technique makes it possible to widen the indications for operation for people with palmar hyperhidrosis.

Endoscopic transthoracic sympathectomy: experience in the south west of England

Thoracic sympathectomy has an established role in the management of primary palmar and axillary hyperhidrosis, Raynaud's phenomenon and occlusive vascular disease. Potential problems with traditional surgical approaches to the sympathetic chain include poor exposure, risk of damage to adjacent structures and postoperative pain. A minimally invasive endoscopic approach helps to overcome these problems. Using this technique, 45 procedures have been performed on 26 patients in two districts in the South West of England over the past five years. Follow-up information was available for 39 procedures. All 27 procedures for hyperhidrosis and both for occlusive vascular disease have produced a long-term improvement. Nine of the 10 procedures for Raynaud's phenomenon have also produced some degree of long-term improvement. Complications included four asymptomatic pneumothoraces, two patients with temporary unilateral Horner's syndrome and two instances of intercosto-brachial numbness. On the positive side, patients expressed satisfaction with the efficacy, rapid recovery and small unobtrusive scars produced by the procedure. Endoscopic transthoracic sympathectomy is effective, safe and well accepted by patients and we believe is now the method of choice for this procedure.

Surgical management of primary hyperhidrosis

Primary hyperhidrosis, although lacking a precise definition and of unknown aetiology, disrupts professional and social life and may lead to emotional problems. A variety of treatment methods are used to control or reduce the profuse sweating which involves mainly the palms, soles and axillae. The simplest method, the application of topical agents, is usually attempted first for axillary and plantar sweating. Iontophoresis may provide relief especially in patients with plantar or palmar involvement. In severe cases operative intervention is necessary. Excision of sweat glands is successful in patients with axillary hyperhidrosis but the role of suction-assisted removal of axillary sweat glands remains to be determined. Sympathectomy remains the standard by which other treatments must be judged. For upper thoracic sympathectomy a variety of surgical approaches are used with satisfactory relief of hyperhidrosis. Complications related to the surgical approach, such as Horner's syndrome, brachial plexus injuries, pneumothorax and painful scars may occur, while following sympathectomy compensatory hyperhidrosis is usual and hyperhidrosis may recur. Plantar hyperhidrosis which may be exacerbated or ameliorated by upper thoracic sympathectomy and which fails to respond to non-operative intervention is relieved by lumbar sympathectomy.

A new strategy of iontophoresis for hyperhidrosis

We used a modified iontophoretic method with an anticholinergic agent and aluminum chloride to treat hyperhidrosis. The strategy behind this combination was to shift gradually from inhibition of sweat gland secretion to blockage of the sweat duct. In a double-blind study in which we compared our method with tap water iontophoresis, the results were comparable. A second study revealed an 87% response rate, with an average remission period of 32 days. Our data indicate that patients who were older at onset, had a family history negative for the disorder, had an early response, or underwent treatment in cool weather had the most favorable results.