Transaxillary thoracic sympathectomy for primary hyperhidrosis of the upper limbs

Percutaneous Phenol Block of the Upper Thoracic Sympathetic Chain with Computed Tomography Guidance

Twenty-one percutaneous neurolyses of the upper thoracic sympathetic chain were performed in 12 patients with CT guidance by a single injection of 1 to 3 ml of phenol at the level of Th3. Results were assessed after a follow-up period varying from 4 to 33 months. Three patients with hyperhidrosis had immediate and complete disappearance of symptoms, but only one patient remained dry. In 7/14 procedures done for Raynaud's disease symptoms disappeared or diminished. These long term results are competitive with surgery. Three transitory Horner syndromes and one pneumothorax occurred.

Évaluation de l’efficacité thérapeutique de la sympatholyse thoracique dans l’hyperhidrose palmaire sous contrôle tomodensitométrique

PURPOSE AND METHOD

Palmar hyperhidrosis is a pathological condition characterized by overperspiration caused by any stress or emotion. We have evaluated the results of 101 CT guided sympatholysis procedures performed on 50 patients suffering from primary palmar hyperhydrosis.

RESULTS

Mean follow up was 50 Months (6 Months to 8 Years) for 87 procedures with immediate good results in 46 patients. Using actuarial analysis, 62% of patients had persistent good results after 50 Months. Complications included one case of small pneumothorax requiring no treatment and one case of vagal syndrome. Pain or thoracic discomfort was reported by 14 patients and was relieved by aspirin within 24 hours. Six patients developed a Horner's syndrome that resolved within a few weeks and six other patients developed moderate compensatory overperspiration over the face, thorax or contralateral arm.

CONCLUSION

Based on our results, CT guided sympatholysis provides results similar to endoscopic thoracic sympathectomy and is associated with fewer risks.

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.

Thoracoscopic cervicodorsal sympathectomy with diathermy

This study reports our experience of using thoracoscopic cervicodorsal sympathectomy with diathermy. From December 1994 to September 1998, we performed 53 thoracoscopic sympathectomies in 35 patients. There were 15 men and 20 women, ages 18 to 61 years. Ten surgeries were performed on the right side, 7 were the left, and 18 were bilateral. Indications for surgery were causalgia/reflex sympathetic dystrophy in 8 patients, Raynaud's/vasculitis in 6, intractable Raynaud's disease in 4, and hyperhydrosis in 17 (bilateral procedure). Operating time ranged from 10 to 50 min for unilateral procedures and from 45 to 80 min for bilateral procedures. Patients stayed in the hospital 1 to 4 days. From favorable immediate and follow-up results we conclude that thoracoscopic cervicodorsal sympathectomy using diathermy is feasible, safe, and effective.

Endoscopic thoracic sympathectomy for primary palmar hyperhidrosis: intermediate term results

BACKGROUND

The authors' experience of the efficacy and safety of endoscopic thoracic sympathectomy in the treatment of primary palmer hyperhidrosis was examined.

METHODS

A retrospective study of 71 patients (126 sympathectomies) was undertaken. Data were retrieved by hospital records and telephone interview.

RESULTS

Follow-up was possible for 92 sympathectomies in 53 patients. Overall, satisfactory results were achieved in 93% of patients and complications were uncommon. Compensatory hyperhidrosis was the most common complication, which occurred in 64% of patients; the trunk and feet were the most common sites. Horner's syndrome occurred in five patients, although in two it was a permanent complication. No patient expressed dissatisfaction with the procedure as a consequence of this complication. Pneumothorax occurred in 17.5% of cases, although the vast majority were incidental findings on a postoperative chest X-ray, and none required drainage. With the newer techniques of access, patient dissatisfaction with the cosmetic appearance has fallen from 27.3 to 6.4%. Overall 90% of patients said they would have the operation again, which represents a high level of patient satisfaction.

CONCLUSIONS

Endoscopic thoracic sympathectomy is a safe and effective technique for primary palmer hyperhidrosis. Evolution of the technique has resulted in improvement in patient satisfaction.

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.

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 thoracic sympathectomy for primary hyperhidrosis of the upper limbs. A critical analysis and long-term results of 480 operations

OBJECTIVE

This evaluated the long-term outcome after endoscopic thoracic sympathectomy (ETS) from below D1 to D4, using a single-site access technique for primary hyperhidrosis of the upper limbs.

SUMMARY BACKGROUND DATA

Primary hyperhidrosis of the upper limbs is a distressing and often socially disabling condition. Endoscopic thoracic sympathectomy is considered the treatment of choice, causing minimal morbidity and high initial success rates. However, data regarding long-term results are scarce.

METHODS

Two hundred seventy of 323 patients (83.7%), in whom 480 sympathectomies were performed, answered a questionnaire after a mean of 14.6 years postoperatively regarding the early postoperative result, side effects, and complications caused by the operation and long-term results with particular emphasis on patient satisfaction.

RESULTS

There was no postoperative mortality and no major complications requiring surgical reintervention. A majority of the patients (98.1%) were relieved, and 95.5% were satisfied initially. Permanent side effects included compensatory sweating in 67.4%, gustatory sweating in 50.7% and Horner's trias in 2.5%. However, patient satisfaction declined over time, although only 1.5% recurred. This left only 66.7% satisfied, and a 26.7% partially satisfied. Compensatory and gustatory sweating were the most frequently stated reasons for dissatisfaction. Individuals operated for axillary hyperhidrosis without palmar involvement were significantly less satisfied (33.3% and 46.2%, respectively).

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.

Long-term results of limited thoracic sympathectomy for palmar hyperhidrosis

Eighteen children (15 females, 3 males) aged 7 to 15 years underwent resection of the thoracic sympathetic chain for severe palmar hyperhidrosis. A localized section of chain immediately below the first thoracic ganglion and including the second thoracic sympathetic ganglion was removed. Patients were followed for 24 to 136 months. All patients had immediate and permanent abolition of palmar hyperhidrosis. There was no mortality, one patient developed intermittent ptosis and myosis, three patients reported compensatory hyperhidrosis and one girl was unhappy with the cosmetic results. We conclude that thoracic sympathectomy is a safe and permanent treatment for severe palmar hyperhidrosis in children. In addition, limited sympathetic resection is associated with a lower incidence of compensatory hyperhidrosis than conventional more radical sympathectomy.

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.

Efficacy of thoracic sympathetic ganglion block and prediction of complications: Clinical evaluation of the anterior paratracheal and posterior paravertebral approaches in 234 patients

In the 10 years from 1980 to 1989, a total of 234 patients underwent 557 thoracic sympathetic ganglion blocks. The block was performed by the anterior paratracheal approach in 129 cases and by the posterior paravertebral approach in 428 cases. The procedures for using these two approaches are presented here. The efficacy of thoracic sympathetic ganglion blockade was evaluated as follows; marked efficacy was defined by the complete control of sweating in the palms, moderate efficacy was defined by a decrease in palmar sweating which persisted for at least one week, and minor efficacy was defined by a decrease in sweating followed by recurrence of hyperhidrosis within one week with maintenance of palmar warmth. in addition, the results were retrospectively reviewed in relation to the age and sex of the patients, the technique used, the laterality of the block, the disease treated, the doses of local anesthetic and neurolytic agents, and the number of blocks. The posterior approach was significantly more successful than the anterior approach, and the treatment of both T2 and T3 by the posterior approach was significantly more effective than the treatment of either nerve alone by the same approach ( P < 0.01). The efficacy rate was significantly lower for hyperhidrosis than for the other diseases ( P < 0.01). Complete cessation of hyperhidrosis was significantly less common in the over-60 age group ( P < 0.01). Regarding the dose of neurolytic, the complete cessation of hyperhidrosis was achieved significantly more frequently with doses of 2.5 ml or higher than with lower doses ( P < 0.01) when both T2 and T3 wee treated by the posterior approach. A dose-dependent response if hyperhidrosis was noted at dose levels higher than 2.5 ml. Thoracic sympathetic ganglion blockade was only occasionally associated with complications, and no serious complications were observed. Before injecting the neurolytic agent, a mixture of contrast medium and local anesthetic was injected to determine the three-dimensional distribution of the contrast and to assess the scope of the analgesia produced by the local anesthetic. Significant complications could thus be avoided.

Telford's operation for primary palmar hyperhidrosis

Bilateral upper dorsal sympathectomy via the supraclavicular approach was performed in 42 patients for palmar hyperhidrosis. In 16 patients (32 extremities) the effect of sympathectomy on digital circulation was evaluated objectively, in comparison with that of 15 control subjects. Mean values of finger temperature and of digital systolic pressure increased by 6.9 degrees C and 36 mmHg respectively after operation, whereas an increase of digital blood flow and a decrease of the time of the clearance of 99mTc by approximately 60% were recorded. Differences between preoperative and postoperative values and those of controls were statistically significant. Clinical results of treatment remain satisfactory after a mean follow-up period of thirty-two months with no case of recurrence. Permanent decrease of plantar hyperhidrosis was recorded by 14 patients. The advantages of Telford's operation over other methods of upper extremity sympathetic denervation are discussed.

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.

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.

Endoscopic transthoracic electrocautery of the sympathetic chain for palmar and axillary hyperhidrosis

Endoscopic transthoracic electrocautery of the sympathetic chain has been the preferred treatment for palmar or axillary hyperhidrosis in this unit since 1980. A retrospective study was carried out of the first 112 patients with case material derived from a postal questionnaire, chart review and outpatient assessment. Eighty-five patients undergoing bilateral transthoracic electrocautery who replied to the questionnaire (76 per cent response rate) form the basis of this study. There were 65 females and 20 males with a mean age of 24.3 years (range 15-40 years). The hands alone were affected in 20 patients (24 per cent), the axillae alone in 17 (20 per cent) and both areas in 48 (56 per cent). Mean hospital stay was 3.1 days (range 1-7 days). Outcome was assessed by 92 per cent of patients immediately after operation as 'very much improved' or 'moderately improved', and this assessment persisted in 85 per cent after a mean follow-up of 43 months (range 3-95 months). Cosmetic results were rated as satisfactory by 95 per cent. Apart from pain after operation, morbidity was limited to transient Horner's syndrome in three patients, surgical emphysema in three, and pneumothorax requiring a chest drain in one. A repeat procedure was needed in one patient because of an inadequate first operation. Some compensatory hyperhidrosis occurred in 54 (64 per cent) patients. As a minimally invasive procedure, endoscopic transthoracic electrocautery should be considered the treatment of choice for palmar and axillary hyperhidrosis.

Treatment of primary hyperhidrosis

Primary hyperhidrosis is a physically and emotionally distressing condition. Physicians should be aware of the various treatment modalities available for controlling or reducing the profuse sweating, which involves mainly the palms, soles, and axillas. The simplest methods, such as topical application of aluminum chloride, should be attempted first. If topical medications are ineffective, iontophoresis may provide relief, especially in patients with plantar or palmar involvement. When patients are unresponsive to other treatment options, surgical intervention may be warranted-excision of sweat glands in patients with axillary hyperhidrosis and upper thoracic sympathectomy in those with palmar involvement. Although excellent results have been reported, complications and resumption of sweating have occurred.