Impact of Video-Assisted Thoracoscopic Sympathectomy and Related Complications on Quality of Life According to the Level of Sympathectomy

Changes in electrodermal activity following sympathicotomy in hyperhidrosis patients

Objectives

The aim of this study was to assess the potential of electrodermal activity (EDA) as a diagnostic tool for preoperative evaluation in hyperhidrosis patients. EDA levels and patterns in different skin areas were investigated before and after endoscopic thoracic sympathicotomy (ETS) and was compared to healthy subjects.

Methods

Thirty-seven patients underwent two days of measurements before and after the operation. Twenty-five (67.5%) of the patients also had a third measurement after six months. Non-invasive EDA measurements, involving skin conductance, were sampled from five different skin areas while patients were at rest in supine and sitting positions or when subjected to stimuli such as deep inspirations, mental challenge, and exposure to a sudden loud sound.

Results

Prior to the operation, hyperhidrosis patients showed higher spontaneous palm EDA variations at rest and stronger responses to stimuli compared to healthy subjects. Patients with facial blushing/hyperhidrosis or combined facial/palmar hyperhidrosis showed minimal spontaneous activity or responses, particularly during mental challenge and sound stimulus. Notably, palm EDA response was abolished shortly following sympathicotomy, although a minor response was observed after six months. Minimal EDA responses were also observed in the back and abdomen postoperatively.

Conclusion

Hyperhidrosis patients showed stronger EDA response to stimuli compared to healthy subjects. Sympathicotomy resulted in the complete elimination of palm EDA responses, gradually returning to a limited extent after six months. These findings suggest that EDA recordings could be utilized in preoperative assessment of hyperhidrosis patients.

Comparing the effectiveness of single-lumen high-frequency positive pressure ventilation with double-lumen endobronchial tube for the anesthesia management of endoscopic thoracic sympathetic blockade surgery

OBJECTIVES

In this trial, we aimed to compare anesthetic effectiveness of single lumen tube (SLT) for tracheal intubation with high-frequency positive pressure ventilation (HFPPV) versus classic double lumen tube (DLT) for tracheal intubation in endoscopic thoracic sympathetic blockade surgery.

DESIGN

This was a prospective randomized controlled clinical study.

SETTING

The study was single-centered and conducted in a university hospital.

PARTICIPANTS

There were 135 endoscopic thoracic sympathetic blockade patients in this study.

INTERVENTIONS

The patients were randomly allocated either to DLT (n = 67) or SLT (n = 68) groups. In SLT group, the ventilator setting was kept with frequencies that range from 1 to 1.8 Hz (60-110/min). Data regarding anesthesia duration, surgery duration, difficult intraoperative lung deflation, postoperative atelectasis, postoperative pain, postoperative pneumothorax were recorded and compared. All patients were operated by a single experienced surgeon under general anesthesia provided by the same anesthesia team.

MEASUREMENTS AND MAIN RESULTS

Both groups were age and gender matched. Among all recorded variables, only anesthesia time was found to be close to statistical significance (P = .059, favoring single lumen). All other parameters were found to be similar between groups. (P < .05).

CONCLUSION

We reported that DLT and single lumen tracheal intubation were equally effective for lung deflation during surgery, and SLT with HFPPV ventilation mode during endoscopic thoracic sympathetic blockade surgery provided the surgeon with an adequate and clean workspace with shorter onset of anesthesia. We may suggest the HFPPV technique for uncomplicated surgery groups or where sufficient conditions for DLT cannot be provided in the operating room.

Use of thoracoscopy for thoracic sympathetic nerve block in primary hyperhidrosis

Thoracic sympathetic nerve block (TSNB) has been widely used in the treatment of neuropathic pain. To reduce block failure rates, TSNB is assisted with several modalities including fluoroscopy, computed tomography, and ultrasonography. The present study describes our experience assessing the usefulness of thoracoscopy in TSNB for predicting compensatory hyperhidrosis before sympathectomy in primary hyperhidrosis. From September 2013 to October 2021, TSNB was performed under local anesthesia using a 2-mm thoracoscope in 302 patients with severe primary hyperhidrosis. Among the 302 patients, 294 were included for analysis. The target level of TSNB was T3 in almost all patients. The mean procedure time was 21 min. Following TSNB, the mean temperature of the left and right palms significantly changed from 31.5 to 35.3 °C and from 31.5 to 34.8 °C, respectively. With TSNB, primary hyperhidrosis was relieved in all patients. Pneumothorax occurred in six patients, in which no chest tube insertion was required. One patient developed hemothorax and was discharged the next day after small-bore catheter drainage. Transient ptosis developed in 10 patients and improved within a day in all patients. Our experiences showed that thoracoscopic TSNB is accurate, safe, and feasible to block the thoracic sympathetic nerve in patients with severe primary hyperhidrosis.

Long-term Outcomes of Endoscopic Thoracoscopic Sympathectomy for Primary Focal Palmar Hyperhidrosis: High Patient Satisfaction Rates Despite Significant Compensatory Hyperhidrosis

BACKGROUND

Endoscopic thoracoscopic sympathectomy (ETS) is the gold standard therapy for primary focal palmar hyperhidrosis (PFPH), resulting in high patient satisfaction rates. The most common side effect of ETS is compensatory hyperhidrosis (CH). Previous studies followed patients' satisfaction degree of surgery and the incidence of CH during a limited follow-up period of 1 to 3 years. The purpose of this study was to investigate the long-term outcomes and patient satisfaction after ETS.

MATERIALS AND METHODS

After approval of our institutional review board, we conducted a retrospective review of all consecutive patients who underwent ETS for PFPH at our institution between 1998 and 2019. Electronic medical records were reviewed for short-term outcomes. Long-term outcomes were collected through telephone questionnaires. Primary outcome was the resolution of PFPH. Secondary outcomes were CH and long-term patient satisfaction.

RESULTS

During the study period, 256 patients underwent ETS to treat primary focal palmar hyperhidrosis at our institution between the years 1998-2019. One-hundred and fifty (58.6%) patients agreed to participate in the study and were included in the final analysis. The mean age was 23.8 (17 to 58) years, 56% were females. The mean follow-up time was 11±6.1 (1 to 22) years. Ninety-four percent reported resolution of PFPH; however, CH was reported by 90% of participants. CH decreased mean patient satisfaction score from 4.8±0.5 to 3.8±2 (P=0.009). This effect was more pronounced in patients with CH of the head and neck (P=0.009). Patients' satisfaction decreased over time from a mean of 4.8±0.4 in the first year after surgery to a mean of 3.7±1.4 12 years or more after surgery (P <0.001). Despite this, 79% of patients reported they would recommend ETS to other patients.

CONCLUSIONS

ETS for PFPH is highly effective and results in high patient satisfaction rates even after long-term follow-up. Despite high rates of postoperative CH, nearly 80% of patients would still recommend the procedure to fellow patients, justifying its reputation as the gold standard treatment for PFPH.

Thoracoscopic resympathectomy for persistent or recurrent palmar hyperhidrosis: single-center experience

BACKGROUND

In case of recurrence or persistent palmar hyperhidrosis, a sympathetic chain resection is suggested, however, many surgeons are still reluctant to offer further intervention because of the inability to predict the efficacy of such a procedure. We analyzed our large series of resympathectomy.

METHODS

Substantive retrospective analysis of 39 patients underwent a resympathectomy (minimally invasive bilaterally sympathetic chain Th2-3 resection). Patients referred from other hospitals or primarily operated at our institution for recurrence or persistence palmar hyperhidrosis were included in the study group.

RESULTS

No intraoperative complications were detected. Reoperation or chest tube positioning was necessary in 2 patients. Twenty-eight patients had a positive response (excellent or good results). Seven patients described a substantial, but not sufficient, reduction of the symptomatology. Four patients were very unsatisfied and regretted the operation.

CONCLUSIONS

Resympathectomy is highly effective procedure for patients who have persistent or recurrent symptoms. However, the indication of the operations should be more dissuasive as possible to avoid the risk of any undesirable psychologically side effects.

How to Prevent, Reduce, and Treat Severe Post Sympathetic Chain Compensatory Hyperhidrosis: 2021 State of the Art

The role of thoracic surgery in the management of hyperhidrosis is well-known and thoracoscopic sympathetic interruption is commonly accepted as being the most effective treatment. However, some concerns still remain regarding the potential to develop compensatory hyperidrosis (CH), the most troublesome and frequent side effect after surgery and its management. Compensatory hyperidrosis prevention may be achieved by identifying subjects at higher risk and/or targeting nerve interruption level on the base of single patient characteristics gathered during the preoperative survey. Furthermore, the surgical treatment may consist of different techniques aimed at reversing the effects of previous sympathetic interruption. To predict CH after sympathectomy, the most interesting proposals in recent literature are a temporary thoracoscopic sympathetic block and the introduction of new and targeted preoperative surveys. If the role of nerve clipping technique vs. the definitive cutting is still intensely under debated, new approaches have been recently proposed to reduce the incidence of CH. In particular, extended sympathicotomy has been described as an alternative to overcome severe forms. Last, among the techniques developed to reverse sympathetic interruption effect, diffuse sympathicotomy (DS) and microsurgical sympathetic trunk reconstruction represent advances in this field. An all-round review of these topics is strongly needed. Our aim is to cover all the above issues point by point. Although sympathectomy represents a small part of thoracic surgery, we believe that it is worthy of interest because of the profound effect that complications for a benign condition can have on patients.

Retroperitoneoscopic lumbar sympathectomy for the treatment of primary plantar hyperhidrosis

Background

Primary plantar hyperhidrosis (PPH) is an idiopathic disease, characterized by excessive sweating of the feet. It leads to significant disturbance in private and professional daily lifestyle, due to excessive sweating. The aim of this study is to present the safety, efficacy and procedures of retroperitoneoscopic lumbar sympathectomy (RLS) for treatment of PPH.

Methods

RLS was performed 60 times in 30 patients (18 men, 12 women) with PPH in our institution from May 2019 to October 2020. All procedures were carried out by laparoscopy with retroperitoneal approach. Clinical data including patient demographics and perioperative, postoperative outcomes were evaluated. Recurrence of symptoms, and any adverse effects of surgery were evaluated after 7 to 30 days in outpatient clinic, and thereafter every 6 months.

Results

Mean age of patients was 33.6 (± standard deviation 10.8) years. Fourteen and fifteen patients were previously treated with medical therapy or endoscopic thoracic sympathectomy (ETS) respectively. Mean preoperative quality of life (QoL) score of patients was 91.8 (VERY BAD), but postoperative 12 months (QoL) score decreased to 29.1 (MUCH BETTER). There was no serious postoperative complication. During the mean 22 months of follow-up period, no compensatory sweating was observed.

Conclusions

RLS can be a safe and effective surgical treatment for severe PPH, especially for the patients with persistent plantar sweating even after conservative management and ETS. RLS also could be offered to surgeons who are familiar with retroperitoneal space anatomy as feasible surgical treatment for PPH.

Evaluation of compensatory hyperhidrosis after sympathectomy: The use of an objective method

OBJECTIVE

To investigate the prevalence of compensatory hyperhidrosis following videothoracic sympathectomy to treat palmoplantar hyperhidrosis and its effect on sweating in the chest, abdomen, back and thighs. Furthermore, to evaluate the concordance between a subjective and an objective method of assessment for compensatory hyperhidrosis.

METHODS

Forty patients with combined palmar and plantar hyperhidrosis who underwent video-assisted thoracoscopic sympathectomy (15 women and 25 men, with a mean age of 25 years) were prospectively followed for 1 year. Subjective and objective parameters were evaluated, using respectively a questionnaire and a sudorometer (Vapometer).

RESULTS

In the subjective analysis, in the first month, only 10% of patients did not have compensatory hyperhidrosis, and 70% continued to report it at 1 or more sites after 1 year. In the objective analysis, 35% of the patients did not present compensatory hyperhidrosis after 1 month, and this number persisted stable, with 30% of patients remaining free of compensatory hyperhidrosis after 1 year. The most frequent area affected by compensatory hyperhidrosis was the back in both assessments. There was no positive concordance between the results of the objective and subjective analysis at any time in any of the 4 regions studied.

CONCLUSIONS

Compensatory hyperhidrosis is a very common postoperative side effect after videothoracic sympathectomy, occurring early after the procedure and persisting for prolonged periods of time. The most frequently affected body area is the back, and no concordance between objective and subjective assessments was observed.

Symptoms of anxiety and depression in patients with primary hyperhidrosis and its association with the result of clinical treatment with oxybutynin

OBJECTIVES

Studies have identified correlations between the psychological characteristics of individuals with primary hyperhidrosis (HH), the degree of sweating, and the quality of life (QoL). This study aimed to evaluate the prevalence of anxiety and depression symptoms in patients with HH before and after oxybutynin treatment.

METHODS

Data were collected from 81 patients. Palmar or axillary HH was the most frequent complaint (84.0%). All patients were evaluated before the medication was prescribed and after five weeks of treatment. The Beck Depression Inventory and Beck Anxiety Inventory were used to evaluate depression and anxiety.

RESULTS

Improvement in HH occurred in 58 patients (71.6%), but there was no improvement in 23 patients (28.4%). The QoL before treatment in all patients was either "poor" or "very poor." Patients who experienced improvement in sweating rates also experienced a greater improvement in QoL than patients who did not experience improvement in sweating at the main site (87.9% vs. 34.7%) (p<0.001). A total of 19.7% of patients showed an improvement in their level of depression, and a total of 46.9% of patients exhibited improvements in their level of anxiety. A significant correlation was observed between sweating and anxiety (p=0.015).

CONCLUSION

Patients with HH who experienced improvements in sweating immediately after treatment with oxybutynin exhibited small improvements in their levels of depression and significant improvements in their levels of anxiety and QoL.

Quality of life after thoracic sympathectomy for palmar hyperhidrosis: a meta-analysis

OBJECTIVE

Palmar hyperhidrosis affects 0.6-10% of the general population, having an important impact in patients' quality of life. The definitive treatment for palmar hyperhidrosis is thoracic sympathectomy. The purpose of this study is to evaluate the quality of life after thoracic sympathectomy for palmar hyperhidrosis.

METHODS

The interest studies were searched in six comprehensive databases. The quality of the studies was assessed using the risk of bias tool recommended by the Cochrane system evaluation manual. Meta-analysis was performed with RevMan version 5.3. The outcome of interest was quality of life. The subgroup analysis and sensitive analysis were performed.

RESULTS

Nine trials, including 895 patients, with accessible data comparing preoperative quality of life score with postoperative quality-of-life score were used for data analysis. Compared with preoperative quality-of-life score, application of thoracic sympathectomy improved the postoperative quality of life of palmar hyperhidrosis patients (MD = 57.81, 95% CI 53.33-62.30). Subgroup analysis of the different thoracic sympathectomy segment showed that there was no significant difference in the results obtained when operated with single segment or multiple segments (single segment: MD = 61.16, 95% CI [56.10, 66.22], multiple segments: MD = 52.14, 95% CI [48.39, 55.88]).

CONCLUSION

The meta-analysis provided evidence of the improved quality of life after thoracic sympathectomy for palmar hyperhidrosis.