The outcome of ganglion clipping in hyperhidrosis and blushing

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 Thoracic sympathetic ablation for hypertension is obsolete, and direct endovascular renal sympathectomy still requires adequate clinical trials.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.

Sympathicotomy for isolated facial blushing: a randomized clinical trial

BACKGROUND

Facial blushing is one of the most peculiar of human expressions. The pathophysiology is unclear, and the prevalence is unknown. Thoracoscopic sympathectomy may cure the symptom and is increasingly used in patients with isolated facial blushing. The evidence base for the optimal level of targeting the sympathetic chain is limited to retrospective case studies. We present a randomized clinical trial.

METHODS

100 patients were randomized (web-based, single-blinded) to rib-oriented (R2 or R2-R3) sympathicotomy for isolated facial blushing at two university hospitals during a 6-year period. Quality of life (QOL) was investigated preoperatively and after 12 months by Short Form 36. Local effects and side effects were assessed by questionnaire.

RESULTS

The male/female ratio was 27/73. The median age was 29 years (range, 18-56 years. The response rate was 93%. QOL increased significantly in all social and mental domains in both groups. Overall, 85% of the patients had an excellent or satisfactory result, with no significant difference between the R2 procedure and the R2-R3 procedure. Mild recurrence of facial blushing occurred in 30% of patients within the first year. One patient experienced Horner's syndrome. Compensatory sweating occurred in 93% of patients, gustatory sweating 36%, and dry hands in 66%; 13% of patients regretted the operation despite thorough preoperative selection and information.

CONCLUSIONS

There were no significant differences in local effects or side effects between R2 and R2-R3 sympathicotomy for isolated facial blushing. Both were effective, and QOL increased significantly. Despite very frequent side effects, the vast majority of patients were satisfied. Surprisingly, many patients experienced mild recurrent symptoms within the first year; this should always be discussed with patients preoperatively.

Sympathetic ablative surgery for palmar and axillary hyperhidrosis

Excessive sweating interferes considerably with daily life; the problem has become more serious because of the increasing popularity of electronic devices. This disorder also affects social activities and can ultimately lead to psychological withdrawal. Treatment for this embarrassing condition is in high demand.

[Results of video-assisted thoracoscopic sympathectomy for facial blushing]

BACKGROUND

Involuntary craniofacial erythema, or blushing, due to autonomic dysfunction can be a cause of psychological distress. Although anecdotal reports have suggested that pharmacologic treatments or cognitive behavioral therapy can be used to treat the condition, no rigorous analyses of their efficacy have been reported.

OBJECTIVES

To assess the efficacy of video-assisted thoracoscopic sympathectomy and to study phobic anxiety and other personality traits in a series of patients with involuntary facial blushing.

MATERIALS AND METHODS

We carried out a retrospective observational study of patients treated with bilateral video-assisted thoracoscopic sympathectomy for blushing over a 7-year period (2001-2008). All the patients were treated by a dermatologist, a psychologist, and a thoracic surgeon and were informed of the predicted outcomes.

RESULTS

A total of 204 patients with a mean age of 34 years (range, 15-67 years) were included; the numbers of males and females were similar. Only 10% had unpredicted outcomes; in such cases, either the procedure was insufficiently effective or postoperative reflex sweating developed (and was considered serious in 2%). There were no deaths and only 1 case of transient Horner syndrome. Video-assisted thoracotomy was required for pleural symphysis in 1 patient; 5 patients developed pneumothorax, but only 1 of them required pleural drainage.

CONCLUSIONS

Video-assisted sympathectomy is a safe, effective and definitive treatment for disabling blushing. Anxiety that is detected before surgery is a reaction to blushing rather than a cause of it.

Botulinum toxin for hyperhidrosis: a review

Primary focal hyperhidrosis is a disorder of idiopathic excessive sweating that typically affects the axillae, palms, soles, and face. The disorder, which affects up to 2.8% of the US population, is associated with considerable physical, psychosocial, and occupational impairments. Current therapeutic strategies include topical aluminum salts, tap-water iontophoresis, oral anticholinergic agents, local surgical approaches, and sympathectomies. These treatments, however, have been limited by a relatively high incidence of adverse effects and complications. Non-surgical treatment complications are typically transient, whereas those of surgical therapies may be permanent and significant. Recently, considerable evidence suggests that botulinum toxin type A (BTX-A) injections into hyperhidrotic areas can considerably reduce focal sweating in multiple areas without major adverse effects. BTX-A has therefore shown promise as a potential replacement for more invasive treatments after topical aluminum salts have failed. This article reviews the epidemiology, diagnosis, and management of primary focal hyperhidrosis, with an emphasis on recent research evidence supporting the use of BTX-A injections for this indication.

The correlation between the method of sympathetic ablation for palmar hyperhidrosis and the occurrence of compensatory hyperhidrosis: a review

BACKGROUND

Upper dorsal sympathectomy achieves excellent long-term results in the treatment of primary palmar hyperhidrosis. Compensatory hyperhidrosis (CHH) remains an unexplained sequel of this treatment, attaining in a small percentage of cases disastrous proportions. It has been claimed that lowering the level of sympathectomy (from T2 to T3 and even T4), substituting resection by other means of ablation, and limiting its extend reduce the occurrence of this sequel. This review was designed to evaluate the validity of these claims.

METHODS

A MEDLINE search was performed for the years 1990--2006 and all publications about thoracoscopic upper dorsal sympathectomy for hyperhidrosis were retrieved.

RESULTS

The search identified 42 techniques of sympathetic ablation. However, pertinent data for the present study were reported for only 23 techniques with multiple publications found only for 10. The only statistically valid results from this review point that T2 resection and R2 transection of the chain (over the second rib) ensue in less CHH than does electrocoagulation of T2. Further comparisons were probably prevented due to the enormous disparity in the reported results, indicating lack of standardization in definitions.

CONCLUSIONS

The compiled results published so far in the literature do not support the claims that lowering the level of sympathetic ablation, using a method of ablation other than resection, or restricting the extend of sympathetic ablation for primary palmar hyperhidrosis result in less CHH. In the future, standardization of the methods of retrieving and reporting data are necessary to allow such a comparison of data.

Short-term and intermediate-term results after unclipping: what happened to primary hyperhidrosis and truncal reflex sweating after unclipping in patients who underwent endoscopic thoracic sympathetic clamping?

Endoscopic thoracic sympathetic clamping (ETC) is used to treat patients with primary hyperhidrosis because it offers the potential of a reversal operation (unclipping) when severe reflex sweating (RS) occurs. Although unclipping has been reported to be effective, the short-term or intermediate-term results after unclipping are unclear. From March 2002 to October 2006, 15 (12.9%) out of 116 patients with primary hyperhidrosis, who underwent ETC, had the endoclip(s) removed as a result of RS. Fourteen patients could be followed up for more than 6 months. The patients answered a telephone interview on the severity of RS, the recurrence of the primary site, and their level of satisfaction. There was no mortality or significant morbidity encountered. On the follow-up, 9 (64%) of the 14 patients who underwent unclipping reported symptomatic recovery from RS. Of these 9 patients with early unclipping (within 4 wk after ETC), only 7 (78%) were satisfied with the outcomes. This suggests that early unclipping does not always guarantee satisfactory recovery from RS. Because early unclipping does not guarantee a full recovery in all patients, special consideration in ETC is needed to determine when to remove the clamp and how strongly to apply the clamp to achieve better results.

Management of facial blushing

Patients complaining of facial blushing should be investigated by a dermatologist or an internist to rule out serious underlying disorders. Patients with emotionally triggered blushing should be encouraged to try nonsurgical options as the first line of treatment. Provided there is still an indication for treatment, facial blushing may be treated effectively by thoracoscopic sympathectomy. The type of blushing likely to benefit from sympathectomy is mediated by the sympathetic nerves and is the uncontrollable, rapidly developing blush typically elicited when one receives attention from other people. Side effects are frequent, but most patients are satisfied with the operation. In the short term, the key to success in sympathetic surgery for facial blushing lies in a meticulous and critical patient selection and in ensuring that the patient is thoroughly informed about the high risk of side effects. In the long term, the key to success in sympathetic surgery for facial blushing lies in more quality research comparing surgical, pharmacologic, and psychotherapeutic treatments.

Sympathectomy for hyperhidrosis: should we place the clamps at T2–T3 or T3–T4?

Endoscopic thoracic sympathectomy is routinely used to treat severe hyperhidrosis. It is usually performed at the T2-T3 level of the nerve, but may produce less severe compensatory hidrosis if performed at a lower level. This study evaluates the outcome of 1,274 patients who underwent endoscopic thoracic sympathectomy for plamar, plantar, axillary or facial hyperhidrosis/blushing. Half of the patients were clamped at the T2-T3 level and half were clamped at the T3-T4 level. Postsurgical symptoms and side effects were assessed by interview. All of patients with palmar hyperhidrosis were cured or improved. Patients with plantar and axillary hyperhidrosis were more likely to be improved at T3-T4 level clamping. Patients with facial hyperhidrosis were more likely to be cured at T2-T3 level, but did show improvement at the T3-T4 level. Overall satisfaction was higher in the T3-T4 group. Some degree of mild compensatory sweating occurred in all patients. However, severe compensatory sweating was more common in the T2-T3 group. Around 2% of patients requested a reversal of their surgery. Endoscopic thoracic sympathectomy is a safe and effective treatment for hyperhidrosis. Clamping at the T3-T4 level has a more successful outcome. In particular, it appears to reduce the incidence of severe compensatory hidrosis.