T3T4 Endoscopic Sympathetic Blockade Versus T3T4 Video Thoracoscopic Sympathectomy in the Treatment of Axillary Hyperhidrosis

[Hyperhidrosis: treatment, results, problems]

OBJECTIVE

To analyze the results of thoracic sympathectomy for hyperhidrosis.

MATERIAL AND METHODS

The study included 166 patients aged from 15-51 years. There were 118 women and 48 men. Isolated palmar hyperhidrosis was observed in 46 patients, axillary - 46 patients, palmar-axillary - 74 cases. Video-assisted thoracic bilateral sympathectomy was performed. In patients with palmar hyperhidrosis, sympathetic chain was transected between the ribs II and III, axillary and palmar-axillary hyperhidrosis - between the ribs III and IV.

RESULTS

Intraoperative injury of intercostal artery occurred in 1 case. Cautery was effective. Postoperative complications occurred in 4 (2.4%) patients (pneumothorax followed by drainage for up to 2-3 days). Symptoms of hyperhidrosis disappeared early after surgery in all cases. Long-term results were followed in 47 patients. Persistent positive effect and patient satisfaction with postoperative outcome were noted in 44 (93.6%) cases. Recurrences occurred in 2 patients with palmar hyperhidrosis and 1 patient with axillary hyperhidrosis for the period from 2 weeks to 6 months. Compensatory sweating developed in 26 (55.3%) patients (within several weeks up to 6 months). Mild compensatory sweating occurred in 17 patients, moderate - 8 patients, severe - 1 patient. Compensatory sweating was more common in patients with axillary and palmar-axillary hyperhidrosis compared to those with isolated palmar hyperhidrosis (p<0.05). We found no significant difference in the incidence of compensatory sweating depending on the level of sympathetic chain intersection (p>0.05).

CONCLUSION

An effectiveness of thoracic sympathectomy for hyperhidrosis is obvious. Compensatory sweating is the main undesirable consequence of this surgery. Prediction and prevention of compensatory sweating are not possible. It is imperative to warn the patient about possible compensatory sweating.

Thoracic sympathectomy for hyperhidrosis: from surgical indications to clinical results

Sympathectomy and its variations have been performed in thoracic surgery for more than 100 years. However, its indications have undergone profound modifications in this period. Likewise, since then the surgical technique has also evolved dramatically up to the minimally invasive techniques worldwide accessible in present days. Currently, primary hyperhidrosis is, by far, the main indication for thoracic sympathectomy and this procedure is usually carried out thoracoscopically with excellent results. However, until today, hyperhidrosis is a part of thoracic surgery still surrounded by controversy, persisting as an open field over which some confusion still resides regarding its pathophysiology, terms definitions and operative approaches. The aim of this article is to provide a wide but easily comprehensible review of the theme, discussing and clarifying the major concepts with respect to its clinical presentation, all the presently available treatment options and strategies with their potential benefits and risks, the adequate patient selection for sympathectomy, as well as the postoperative clinical results.

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.

Long-term results of endoscopic sympathetic block using the Lin-Telaranta classification

BACKGROUND

Endoscopic thoracic sympathectomy has been used successfully in the treatment of blushing, excessive sweating, and social phobia. However, the adverse effects of endoscopic thoracic sympathectomy are more severe and frequent than the adverse effects of endoscopic sympathetic block (ESB). The use of different blocking levels for different indications in ESB according to the Lin-Telaranta classification further decreases the postoperative adverse effects. However, there are few data on the long-term results of ESB performed using the Lin-Telaranta classification.

METHODS

Ninety-five patients (55 men, 40 women) were interviewed by before the surgery using our routine questionnaire, and the same questionnaire was answered postoperatively by the patients. In addition, a long-term follow-up questionnaire was sent to all patients whose address was known. Forty-seven patients (24 men, 23 women) answered to this questionnaire. The Davidson brief social phobia scale and the Liebowitz quality of life scale were used. Patients were divided to 3 categories: category 1, patients with sweating problems; category 2, patients with blushing; and category 3, and patients with symptoms other than sweating or blushing.

RESULTS

Among patients in category 1, social phobia decreased from 12.43 to 6.71 (p = 0.004), in category 2 from 13.97 to 7.69 (p < 0.001), and in category 3 from 13.18 to 9.64 (p = 0.007) during long-term follow-up. Among patients with severe sweating problems preoperatively, sweating decreased from 2.50 to 1.29 (p = 0.003) among patients in category 1 and from 1.86 to 1.16 (p < 0.001) among patients in category 2. Among patients with unbearable blushing, blushing decreased from 4 to 1.80 (p < 0.001).

CONCLUSIONS

Patients got a clear help from ESB performed using the Lin-Telaranta classification to treat blushing, excessive sweating, and social phobia with and without physical symptoms. In addition, compensatory sweating increased only slightly.

Evaluation of the damage caused by clamping or section of cervical sympathetic nerve in rabbits

PURPOSE

To study the macro and microscopic evaluation of the damage caused by clamping or section of cervical sympathetic nerve in rabbits, quantifying the collagen in the lesions.

METHODS

Twenty rabbits were divided into two groups of ten, doing in group 1 (section) section of the right cervical sympathetic nerve, while in group 2 (clipping) clipping of the nerve. All rabbits were induced to death on the seventh day after surgery. The macroscopic variables were: consequences of nerve lesion, clip appearance, presence of infection and adhesions around the nerve. Microscopy used hematoxylin-eosin staining to evaluate the stages and the degree of inflammation and necrosis, and F3BA Picrosirius red staining to quantify collagen. Mann-Whitney test was used for comparisons of collagen types I and III between groups. Fisher exact test analyzed the macroscopic variables, the degree of inflammation and necrosis.

RESULTS

There was no discontinuity of nerve injury in the clipping group, as well as the clip was closed in all animals. The presence of severe adhesions was significantly higher in the clipping group (p<0.05). There was no significant difference on other variables macroscopically analyzed. There was no significant difference between groups regarding the type of inflammatory process and its intensity, as well as the presence of necrosis and collagen deposition in the nerves.

CONCLUSIONS

In the macroscopic evaluation, the section caused discontinuity, which did not occur in the clamping group; there was no development of local infection; the clipping of the cervical sympathetic nerve was linked to the presence of a greater number of adhesions in comparison to the section group. Microscopically, no difference existed in relation to the type and intensity of inflammation reaction between the groups; occurred predominance of chronic and severe inflammation on the specimens; the necrosis was noticed equally in both groups; there was predominance of type I collagen deposition in relation to type III in both groups.

[Initial experience of a program of clipping the sympathetic nervous system for the treatment of hyperhidrosis and facial flush]

INTRODUCTION AND OBJECTIVE

To evaluate the results of our program of clipping the thoracic sympathetic nervous system (TSNS) for the treatment of facial flush and/or hyperhidrosis (HH), and to compare the methodology-results of the program development phase (A: January 2007-April 2009) and its consolidation phase (B: May 2009-March 2010).

MATERIAL AND METHODS

The program included a total of 44 patients (88 procedures) subjected to videothoracoscopy and clipping of the TSNS in a one day surgery unit. Data were collected and analysed retrospectively, and a descriptive and comparative statistical analysis was performed between the two periods (A and B).

RESULTS

The overall morbidity was 5 cases (11.3%). The post-surgical occurrence rate of HH was 4.54% (2 cases), and the incidence of compensatory sweating was 65.9% (minimal in 26 of the 29 cases). On comparing period B with period A, there was a significant decrease in surgical time, disappearance of recurrence of HH, a decrease of 30% in morbidity, reduction by half in the incidence of moderate to severe compensatory sweating, and an increase in the level of satisfaction. The clamps were removed in one of the poorly tolerated compensatory sweating cases, resulting in its disappearance.

CONCLUSIONS

Clipping the TSNS is a safe technique in the one day surgery unit, with a short learning curve (20 cases) after which comparable, or even better, results are obtained than those of sympatholysis. These results, together with their potential reversibility, makes it, in our opinion, the technique of choice in the surgery of the TSNS.

Primary focal hyperhidrosis: current treatment options and a step-by-step approach

Primary focal hyperhidrosis is a common disorder for which treatment is often a therapeutic challenge. A systematic review of current literature on the various treatment modalities for primary focal hyperhidrosis was performed and a step-by-step approach for the different types of primary focal hyperhidrosis (axillary, palmar, plantar and craniofacial) was established. Non-surgical treatments (aluminium salts, local and systemic anticholinergics, botulinum toxin A (BTX-A) injections and iontophoresis) are adequately supported by the current literature. More invasive surgical procedures (suction curettage and sympathetic denervation) have also been extensively investigated, and can offer a more definitive solution for cases of hyperhidrosis that are unresponsive to non-surgical treatments. There is no consensus on specific techniques for sympathetic denervation, and this issue should be further examined by meta-analysis. There are numerous treatment options available to improve the quality of life (QOL) of the hyperhidrosis patient. In practice, however, the challenge for the dermatologist remains to evaluate the severity of hyperhidrosis to achieve the best therapeutic outcome, this can be done most effectively using the Hyperhidrosis Disease Severity Scale (HDSS).