Effects of endoscopic thoracic sympathectomy for primary hyperhidrosis on cardiac autonomic nervous activity

Hyperhidrosis, Endoscopic Thoracic Sympathectomy, and Cardiovascular Outcomes: A Cohort Study Based on the Korean Health Insurance Review and Assessment Service Database

Sympathetic overactivity is associated with hyperhidrosis and cardiovascular diseases. Endoscopic thoracic sympathectomy (ETS) is a treatment for hyperhidrosis. We aimed to compare the risk for cardiovascular events between individuals with and without hyperhidrosis and investigate the effects of ETS on cardiovascular outcomes. We conducted a nationwide population-based cohort study using data acquired from the Korean Health Insurance Review and Assessment Service. Subjects newly diagnosed with hyperhidrosis in 2010 were identified and divided into two groups according to whether or not they underwent ETS. Propensity scores were calculated using a logistic regression model to match hyperhidrosis patients with control subjects. Combined cardiovascular events were defined as stroke and ischemic heart diseases. Subjects were followed up until the first cardiovascular event or 31 December 2017. The risk for cardiovascular events with hyperhidrosis and ETS was analyzed using Cox proportional hazards regression analysis. The risk for stroke was significantly higher in the hyperhidrosis group than in the control group (hazard ratio (HR), 1.28; 95% confidence interval (CI), 1.08-1.51); nonetheless, no significant difference in the risk for ischemic heart diseases was observed between the hyperhidrosis group and the control group (HR, 1.17; 95% CI, 0.99-1.31). Hyperhidrosis patients who did not undergo ETS were at significantly higher risk for cardiovascular events than the control group (HR, 1.28; 95% CI, 1.13-1.45). However, no significant difference in the risk for cardiovascular events was observed between hyperhidrosis patients who underwent ETS and the control group. Hyperhidrosis increases the risk for cardiovascular events. ETS could reduce this risk and needs to be considered for high-risk patients with cardiovascular diseases.

Longitudinal follow-up of cardiac vagal activity in individuals undergoing endoscopic thoracic sympathectomy

OBJECTIVE

To conduct a longitudinal investigation of cardiac vagal activity (CVA) by measuring resting HR and calculating the cardiac vagal index (CVI) in individuals undergoing sympathectomy for the treatment of primary hyperhidrosis.

METHODS

This was a descriptive longitudinal study involving 22 patients, 13 of whom were female. The mean age was 22.5 ± 8.8 years. The palms, soles, and axillae were the most commonly affected sites. Resting HR was measured by an electrocardiogram performed 20 min before the 4-second exercise test (4sET), which was used in order to evaluate CVA at three different time points: before surgery, one month after surgery, and four years after surgery.

RESULTS

Resting HR (expressed as mean ± SE) was found to have decreased significantly at 1 month after surgery (73.1 ± 1.6 bpm before surgery vs. 69.7 ± 1.2 bpm at one month after surgery; p = 0.01). However, the HR values obtained at four years after surgery tended to be similar to those obtained before surgery (p = 0.31). The CVI (expressed as mean ± SE) was found to have increased significantly at one month after surgery (1.44 ± 0.04 before surgery vs. 1.53 ± 0.03 at one month after surgery; p = 0.02). However, the CVI obtained at four years after surgery tended to be similar to that obtained before surgery (p = 0.10).

CONCLUSIONS

At one month after sympathectomy for primary hyperhidrosis, patients present with changes in resting HR and CVA, both of which tend to return to baseline at four years after surgery.

Supraventricular arrhythmias after thoracotomy: is there a role for autonomic imbalance?

Supraventricular arrhythmias are common rhythm disturbances following pulmonary surgery. The overall incidence varies between 3.2% and 30% in the literature, while atrial fibrillation is the most common form. These arrhythmias usually have an uneventful clinical course and revert to normal sinus rhythm, usually before patent's discharge from hospital. Their importance lies in the immediate hemodynamic consequences, the potential for systemic embolization and the consequent long-term need for prophylactic drug administration, and the increased cost of hospitalization. Their incidence is probably related to the magnitude of the performed operative procedure, occurring more frequently after pneumonectomy than after lobectomy. Investigators believe that surgical factors (irritation of the atria per se or on the ground of chronic inflammation of aged atria), direct injury to the anatomic structure of the autonomic nervous system in the thoracic cavity, and postthoracotomy pain may contribute independently or in association with each other to the development of these arrhythmias. This review discusses currently available information about the potential mechanisms and risk factors for these rhythm disturbances. The discussion is in particular focused on the role of postoperative pain and its relation to the autonomic imbalance, in an attempt to avoid or minimize discomfort with proper analgesia utilization.

Thoracoscopic sympathectomy increases efferent cardiac vagal activity and baroreceptor sensitivity

OBJECTIVES

Thoracoscopic sympathectomy at levels T2 or T2-T3 is a treatment for focal hyperhidrosis and facial blushing. These levels of the sympathetic trunk innervate the heart, and consequently, the procedure is reported to change the heart rate variability due to changes in efferent cardiac autonomic activity. Our objective was to investigate the effects of thoracoscopic sympathectomy on global autonomic control, including baroreceptor sensitivity.

METHODS

Eight patients (6 F, median age 28 years [range 20-58 years]) were exposed to the tilt-table test and cardiopulmonary exercise test before, and 3 months after, thoracoscopic sympathectomy. Eight healthy age-, gender- and BMI-matched controls were used as controls and underwent the same tests once. During tilt-table testing electrocardiogram, blood pressure, impedance cardiography and respiration were measured continuously, and efferent cardiac autonomic balance was estimated.

RESULTS

The heart rate measured during orthostatic stress test was lowered after thoracoscopic sympathectomy (between-group; P = 0.01) due to a change in autonomic tone, with increased vagal (high-frequency power n.u.; P = 0.001), and reduced sympathetic efferent cardiac activity (low-frequency power n.u.; P < 0.001). Baroreceptor sensitivity measured during rest was increased (26 ± 13 vs 44 ± 19 ms/mmHg; P = 0.01), and diastolic blood pressure reduced after surgery (P = 0.01). The increases in systolic blood pressure and the sympathetic marker CCV-LF in response to orthostatic stress were higher before sympathectomy, with almost no increases post-surgically (condition × group interaction; P = 0.01 and P = 0.001, respectively). We found no change in post-procedure exercise capacity, although patients had a lower peak VO2 and maximal cardiac index than controls.

CONCLUSIONS

Thoracoscopic sympathectomy changes the autonomic tone towards increased vagal activity; this is potentially cardioprotective. To our knowledge, this is the first study to show increased baroreceptor sensitivity after thoracoscopic sympathectomy.

Thoracoscopic Sympathectomy for Hyperhidrosis

BACKGROUND

Hyperhidrosis (HH) profoundly affects a patient's well-being.

OBJECTIVE

We report indications and outcomes of 322 patients treated for HH via thoracoscopic sympathectomy or sympathotomy at the Barrow Neurological Institute.

METHODS

A prospectively maintained database of all patients who underwent sympathectomy or sympathotomy between 1996 and 2008 was examined. Additional follow-up was obtained in clinic, by phone, or by written questionnaire.

RESULTS

A total of 322 patients (218 female patients) had thoracoscopic treatment (mean age 27.6 years; range, 10–60 years). Mean follow-up was 8 months. Presentations included HH of the palms (43 patients, 13.4%), axillae (13 patients, 4.0%), craniofacial region (4 patients, 1.2%), or some combination (262 patients, 81.4%). Sympathectomy and sympathotomy were equally effective in relieving HH. Palmar HH resolved in 99.7% of patients. Axillary or craniofacial HH resolved or improved in 89.1% and 100% of cases, respectively. Hospital stay averaged 0.5 days. Ablating the sympathetic chain at T5 increased the incidence of severe compensatory sweating (P = .0078). Sympathectomy was associated with a significantly higher incidence of Horner's syndrome compared with sympathotomy (5% vs 0.9%, P = .0319). Patients reported satisfaction and willingness to undergo the procedure again in 98.1% of cases.

CONCLUSION

Thoracoscopic sympathectomy is effective and safe treatment for severe palmar, axillary, and craniofacial HH. Ablating the T5 ganglion tends to increase the severity of compensatory sweating. Sympathectomy led to a higher incidence of ipsilateral Horner's syndrome compared with sympathotomy.

Biportal thoracoscopic sympathectomy for palmar hyperhidrosis in adolescents

OBJECT

Palmar, axillary, and plantar hyperhidrosis is often socially, emotionally, and physically disabling for adolescents. The authors report surgical outcomes in all adolescents treated for palmar hyperhidrosis via bilateral thoracoscopic sympathectomy at the Barrow Neurological Institute by the senior author.

METHODS

A prospectively maintained database of all adolescent patients undergoing bilateral thoracoscopic sympathectomy between 1998 and 2006 (inclusive) was reviewed. Additional follow-up was obtained as needed in clinic or by phone or written questionnaire.

RESULTS

Fifty-four patients (40 females) undergoing bilateral procedures were identified. Their mean age was 15.4 years (range 10-17 years). Average follow-up was 42 weeks (range 0.2-143 weeks). Hyperhidrosis involved the palms alone in 10 patients; the palms and axilla in 6 patients; the palms and plantar surfaces in 17 patients; and the palms, axilla, and plantar surfaces in 21 patients. Palmar hyperhidrosis resolved completely in 98.1% of the patients. Resolution or improvement of symptoms was seen in 96.3% of patients with axillary and 71.1% of those with plantar hyperhidrosis. Hospital stay averaged 0.37 days with 68.5% of patients discharged the day of surgery. One patient experienced brief intraoperative asystole that resolved with medications and had no long-term sequelae. Otherwise, no serious intraoperative complications occurred. No patient required chest tube drainage. The percentage of patients who reported satisfaction and willingness to undergo the procedure again was 98.1%.

CONCLUSIONS

Biportal, bilateral thoracoscopic sympathectomy is an effective and low-morbidity treatment for severe palmar, axillary, and plantar hyperhidrosis.