Thoracoscopic excision of the sympathetic chain: an easy and effective treatment for hyperhidrosis in children

Over a decade of single-center experience with thoracoscopic sympathicolysis for primary palmar hyperhidrosis: a case series

BACKGROUND

Primary palmar hyperhidrosis is a severely debilitating condition that can affect patients of any age. We report our experience with thoracoscopic sympathicolysis in a large cohort of children less than 14 years of age.

METHODS

All children who underwent thoracoscopic sympathicolysis from April 2005 through January 2017 were evaluated retrospectively. The procedure entailed bilateral bipolar fulguration of the second and third thoracic ganglia with transverse disruption of collateral nerve fibers along the third and fourth rib. Demographic information, as well as postoperative outcome, complications, and satisfaction were analyzed.

RESULTS

Over the 12 year study interval, a total of 102 children underwent thoracoscopic sympathicolysis for palmar hyperhidrosis. Complete follow-up was available for 98 patients (median age 12 [range 5-14] years; 38 boys [39%]). Median follow-up was 4 [range 2-12] years. Complete palmar dryness was achieved in 93 (95%) cases. One patient suffered postoperative unilateral ptosis, 6 reported gustatory sweating, and 65 experienced compensatory sweating. Average postoperative rating on a 1 (lowest) to 10 (highest) rating scale was 9, with 97 (99%) patients saying that they would undergo the procedure again.

CONCLUSION

Our technique of thoracoscopic sympathicolysis in children was associated with very high postoperative satisfaction, despite a high rate of compensatory sweating and occasional autonomic gustatory sweating. Other more severe complications in this age group were rare.

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.

Thoracoscopic bilateral T3 sympathectomy for primary focal hyperhidrosis in children

AIM OF THE STUDY

Present our experience in the surgical treatment of primary focal hyperhidrosis of the hands by thoracoscopic bilateral T3 sympathectomy in pediatric patients.

METHODS

Retrospective chart review of all patients operated between 2013 and 2015.

RESULTS

We operated and included in the study 28 patients, 22 females and 6 males. Mean age was 14 (6-21) years. All patients had previously tried at least one form of medical therapy with no success. All patients were extensively counseled regarding the potential side effects of the sympathectomy. The operations were done in supine position with the arms extended. All patients were intubated with a double-lumen endotracheal tube for sequential lung isolation. We used a 5-mm port for the scope and a 3-mm port for the instruments, both placed in the axilla. The third rib was identified by fluoroscopy. The sympathectomy was done with monopolar cautery. Mean operative time was 43 (25-71) minutes. No chest tubes were used. The incidence of intraoperative or postoperative complications was zero. All patients were discharged within the first 24 postoperative hours. All patients achieved immediate complete postoperative resolution of the palmar hyperhidrosis, sustained in all cases at a median follow-up of 17 (2-34) months. The mean preoperative quality of life score (based on a multifunctional self-assessment questionnaire) was 41/100, whereas after the operation, it was 92/100. Only 1 patient developed temporary compensatory sweating. All patients were satisfied with the result of the operation.

CONCLUSION

Thoracoscopic bilateral T3 sympathectomy is a safe and effective treatment for children and adolescents with primary focal hyperhidrosis of the hands who failed medical management and have a very low rate of compensatory sweating.

LEVEL OF EVIDENCE

IV.