Endoscopic transthoracic sympathectomy: experience in the south west of England

Thoracoscopic sympathectomy for palmar hyperhidrosis

BACKGROUND

Upper thoracoscopic sympathectomy, obtained either by ablation or resection of the appropriate ganglia, is now the preferred treatment for primary palmar hyperhidrosis. Therefore, we undertook a review to compare the relative efficacy of these two techniques.

METHODS

A Medline search was performed for the years 1974-99 to identify all published studies of thoracoscopic sympathectomy for hyperhidrosis.

RESULTS

In all, 33 studies were identified and divided into two groups-ablation and resection. When the resection method was used, the immediate success rate was 99.76%, whereas the ablation method achieved dry hands in 95.2% of cases (p = 0.00001). Palmar sweating recurred in 0% of patients treated via resection and -4.4% treated with ablation. Ptosis was noted in 0.92% of cases after ablation and in 1.72% after resection (p = 0.017).

CONCLUSIONS

Resection yields superior results, yet the majority of surgeons ablate, probably because it is easier, requires a shorter operating time, leads to fewer cases of Horner's syndrome, and because resympathectomy eventually overcomes initial failure.

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.

Randomisierte, plazebokontrollierte klinische Doppelblindstudie zur Wirksamkeit und Vertraglichkeit der oralen Therapie mit Methantheliniumbromid (VagantinR) bei fokaler Hyperhidrose. Randomized, placebo-controlled, double blind clinical trial for the evaluation of the efficacy and safety of oral methantheliniumbromide (VagantinR) in the treatment of focal hyperhidrosis

BACKGROUND

Methanthelinium bromide is a quaternary ammonium derivate with anticholinergic activity. Since 1951 it has been used to treat patients with hyperhidrosis. However, all efficacy data has so far been limited to case reports and case series. We here report on the results of the first randomised clinical controlled trial on the efficacy and safety of methanthelinium bromide.

PATIENTS AND METHODS

A total of 41 patients with a mean age (+/- standard deviation) of 28 +/- 9.8 years (Range 18.7-54.8) were included, 31 (76%) of them were females. Main inclusion criteria were are focal hyperhidrosis of a one year or longer duration and a gravimetrically assessed sweat production of > or =50 mg/min. Patients were treated with 2 x 50 mg methanthelinium bromide or placebo orally daily for 4 weeks. The therapeutic effect was determined by repeated gravimetric measurement of sweat production and by recording the patients' degree of satisfaction.

RESULTS

The efficacy was most pronounced for patients with an axillary hyperhidrosis of > or =50 mg/min (p = 0.02, chi2-test, two-sided). For the total group the main axillary sweat production decreased in the verum-treated arm from a mean value of 89.2 +/- 73.4 mg/min prior to therapy to 53.3 +/- 48.7 mg/min during therapy (p = 0.02, Wilcoxon test, two-sided). In contrast, no difference was detected in the placebo arm with 60.7 +/- 42.8 mg/min prior to and 59.1 +/- 40.6 mg/min during therapy (p = 0.92, Wilcoxon test, two-sided). For the palmar sweat production no difference between the verum- and the placebo-treated group was found. No serious adverse events were reported. As expected, dryness of the mouth, a known adverse reaction of anticholinergics, was reported significantly more frequently in the verum-treated arm.

CONCLUSIONS

Methanthelinium bromide has been considered for many years as a therapeutic option for the treatment of focal hyperhidrosis. However, its efficacy and safety have not previously been investigated in controlled randomised studies. We demonstrated both a decline in axillary sweat production and good tolerance. Therefore, the treatment of axillary hyperhidrosis with methanthelinium bromide in a regimen of 50 mg twice daily can be recommended, especially in those cases which are refractory to topical treatment with for example aluminium chloride hexahydrate solution. In contrast, we found no evidence for a clinically relevant diminution of palmar sweating.

Video-assisted thoracoscopic sympathectomy for palmar hyperhidrosis: results in 102 cases

The purpose of this retrospective study was to evaluate the immediate and long-term outcome of video-assisted thoracoscopic sympathectomy for idiopathic palmar hyperhidrosis. Between January 1996 and December 2000, a total of 67 patients underwent 102 sympathectomy procedures with excision of the sympathetic chain between the second and fourth sympathetic ganglion. The mean duration of hospitalization was 1.7 +/- 0.6 days. Five patients were lost to follow-up. Mean duration of follow-up for the 96 sympathectomy procedures in the remaining 62 patients was 38 +/- 6.3 months. Patient outcome showed that video-assisted thoracoscopic sympathectomy is the treatment of choice for idiopathic palmar hyperhidrosis. Long-term patient satisfaction is excellent.

Thoracoscopic sympathectomy for palmar hyperhidrosis and Raynaud's phenomenon of the upper limb and excessive facial blushing: a five year experience

Primary hyperhidrosis of the palms, face, and axillae has a strong negative impact on social and professional life. A retrospective analysis of 40 laparoscopic transaxillary thoracic sympathectomies performed in a district general hospital over a five year period was undertaken in order to determine the effectiveness of this procedure. A postal questionnaire was sent to all patients to assess the benefit from the operation; postoperative pain and time off work were collated. Immediate failure was noted in three patients, of whom two later underwent successful reoperation. Recurrence was noted in three patients (8%). Though immediate complications were minimal, the major long term postoperative morbidity was compensatory hyperhidrosis on the back, chest, and thigh (77%) along with gustatory sweating over the face (22%). Thoracoscopic sympathectomy is a safe, effective, and minimally invasive surgical treatment for hyperhidrosis, Raynaud's phenomenon of the upper limb, and excessive facial blushing; however, the chance of long term compensatory hyperhidrosis is high.

Long-term assessment of percutaneous stereotactic thermocoagulation of upper thoracic ganglionectomy and sympathectomy for palmar and craniofacial hyperhidrosisin 1742 cases

OBJECTIVE

We sought to determine the long-term outcome of percutaneous stereotactic thermocoagulation for upper thoracic ganglionectomy and sympathectomy in patients with palmar and craniofacial hyperhidrosis with the use of a three-dimensional system of coordinates for the location of the T2 and T3 ganglia on the basis of the findings in a cadaveric study.

METHODS

From November 1986 to May 1998, upper thoracic ganglionectomy and sympathectomy with the use of percutaneous stereotactic thermocoagulation were performed in 1688 patients with palmar hyperhidrosis and 54 patients with craniofacial hyperhidrosis as outpatient surgical procedures based on a three-dimensional coordinate system for determining the location of the thermocoagulation point, which was developed by the authors in a cadaveric study. The technique requires only local anesthesia.

RESULTS

After initial thermocoagulation, sweating stopped in 3465 (99.5%) of 3484 sides. Hyperhidrosis recurred within 2 to 59 months of treatment in 268 procedures. All patients in whom hyperhidrosis recurred were retreated successfully, resulting in a final success rate of 99.9%. Complications of treatment included pneumothorax in seven procedures (0.2%) and partial Horner's syndrome in five procedures (0.15%). Decreased plantar sweating was noted during follow-up in 92% of patients.

CONCLUSION

The results of this study indicate that upper thoracic ganglionectomy and sympathectomy performed with the use of percutaneous thermocoagulation are a very effective treatment for palmar and craniofacial hyperhidrosis that provides excellent immediate and long-term results as well as a low complication rate. The method is also effective as a retreatment for recurrences. Our data also suggest that performing ganglionectomy and sympathectomy in both T2 and T3 is unnecessary, because the procedure had equal long-term effectiveness when performed in T2 alone.

Are We Paying a High Price for Surgical Sympathectomy? A Systematic Literature Review of Late Complications

The purpose of this article was to systematically review the literature in order to assess (1) the current indications for surgical sympathectomy and (2) the incidence of late complications collectively and per indication. All types of upper or lower limb surgical sympathectomies are included. An extensive search strategy looked for controlled trials and observational studies or case series with an english abstract. Out of 1,024 abstracts from MEDLINE and 221 from EMBASE, 135 articles reporting on 22,458 patients and 42,061 procedures (up to april 1998) fulfilled the inclusion criteria. Weighted means were used to control for heterogeneity of data. No controlled trials were found. The main indication was primary hyperhidrosis in 84.3% of the patients. Compensatory hyperhidrosis occurred in 52.3%, gustatory sweating in 32.3%, phantom sweating in 38.6%, and horner's syndrome in 2.4% of patients, respectively, with cervicodorsal sympathectomy, more often after open approach. Neuropathic complications (after cervicodorsal and lumbar sympathectomy) occurred in 11.9% of all patients. Compensatory hyperhidrosis occurred 3 times more often if the indication was palmar hyperhidrosis instead of neuropathic pain (52.3% versus 18.2%), whereas neuropathic complications occurred 3 times more often if the treatment was for neuropathic pain instead of palmar hyperhidrosis (25.2% versus 9.8%). Surgical sympathectomy, irrespective of approach, is accompanied by several potentially disabling complications. Detailed informed consent is recommended when surgical sympathectomy is contemplated.

Skin wrinkling for the assessment of sympathetic function in the limbs

BACKGROUND

Wrinkling of the skin of the palm and sole is considered to be dependent on the presence of intact sympathetic nervous activity. Loss of sympathetic integrity could be simply and usefully assessed by the absence of wrinkling. To test this hypothesis, the skin wrinkle test was compared with the starch-iodine sweat test and sympathetic skin response (SSR) in patients with abnormal sympathetic function.

METHODS

The three tests were carried out in 34 patients (68 limbs) undergoing temporary or permanent disruption of the sympathetic chain to upper or lower limbs. Included in this group were six diabetics undergoing chemical or surgical sympathectomy, lumbar epidural infusions following vascular surgery, and patients for whom sympathectomy was being considered. Sensitivity and specificity analysis and predictive values of the wrinkling response and the starch-iodine test were related to the SSR as the standard.

RESULTS

The wrinkle test showed a sensitivity of 97% and specificity of 95%, and bore good correlation to the SSR. The starch-iodine test showed sensitivity of 55% and specificity of 93%. A hypothesis for the mechanism of wrinkling based on the observations of the present study is proposed.

CONCLUSION

The wrinkle test is a reliable test of sympathetic function, is inexpensive and is easy to perform at the bedside. The sweat gland myo-epithelial cells and absence of sebum could play an important role in the wrinkling response. It can be used to select patients who will benefit from sympathectomy, and can adequately evaluate sympathetic blockade.

Sympathetic skin response and patient satisfaction on long-term follow-up after thoracoscopic sympathectomy for hyperhidrosis

OBJECTIVES

To determine effect of sympathectomy for hyperhidrosis on sympathetic skin response (SSR) during long-term follow-up. Patient satisfaction was assessed and surgical complications noted.

DESIGN

Prospective, Open, Non-randomised study.

MATERIALS AND METHODS

Patients who had undergone bilateral thoracoscopic sympathectomy for hyperhidrosis underwent postoperative assessment of SSRs. A 15 mA stimulus was applied over the median nerve contralateral to the sympathectomy and evoked electrodermal activity was recorded from the sympathectomised palm using a Dantec Counterpoint Mk 2. Patient satisfaction with surgery was assessed by questionnaire and visual analogue score (0-1.0).

RESULTS

Of 26 patients, 21 were female. Mean (range) age was 23 (9-36) years. Mean (range) follow up was 39 (4-138) months. 12% of cases had residual or recurrent symptoms. Median (range) patient satisfaction was 0.83 (0.06-1.0). In 7/52 palms recurrent SSRs were not detected. Repeated measures analysis of variance found amplitude of SSR to be of low significance with respect to time since surgery (F = 0.48; p = 0.49) and incidence of compensatory sweating (F = 2.38; p = 0.14).

CONCLUSION

Thoracoscopic sympathectomy for hyperhidrosis is an effective procedure. Following sympathectomy SSRs are not permanently abolished, but return of SSRs does not correspond with symptom recurrence. As such, SSRs are a poor tool for objective assessment of long-term outcome following sympathectomy.

Total intravenous anesthesia and high-frequency jet ventilation during transthoracic endoscopic sympathectomy for treatment of essential hyperhidrosis palmaris: a new approach

OBJECTIVE

To evaluate the effects of high-frequency jet ventilation (HFJV) applied to both lungs on hemodynamic parameters, oxygenation, and operating conditions during bilateral videothoracoscopic sympathectomy.

DESIGN

A prospective, unblinded study.

SETTING

An ambulatory surgical unit at a university medical center.

PARTICIPANTS

30 patients (11 men, 19 women), ASA status 1.

INTERVENTION

Bilateral videothoracoscopic sympathectomies were performed using total intravenous anesthesia with propofol, alfentanil, and atracurium, and the patients were ventilated with an oxygen-air mixture using HFJV delivered to both lungs with a Hi-Lo Jet tracheal tube (Mallinckrodt).

MEASUREMENTS AND MAIN RESULTS

Mean total anesthesia time was 55 +/- 13 minutes. Hemodynamic parameters remained stable during surgery, although ablation of the sympathetic ganglia induced three incidences of bradycardia (10% of the patients), which were responsive to atropine. Four patients developed oxygen desaturation (Sa O2 < 90%) after the creation of the pneumothorax. Surgical conditions were considered excellent by the surgeons. Concerning postoperative complications, a temporary Horner's syndrome was observed in one patient. Another patient had a mild residual pneumothorax on the first postoperative day that resolved without insertion of a chest tube.

CONCLUSIONS

It was concluded that HFJV applied to both lungs is an easy and safe anesthetic technique that provides excellent surgical conditions and causes a minor incidence of morbidity.

A simplified T2-T3 thoracoscopic sympathicolysis technique for the treatment of essential hyperhidrosis: short-term results in 100 patients

A simplified one-time bilateral thoracoscopic T2-T3 sympathicolysis technique using single-lumen endotracheal intubation with high frequency jet ventilation and electrocautery destruction ("sympathicolysis") of the sympathetic ganglia was applied in 100 consecutive patients with severe essential hyperhidrosis (EH). Providing a pleural space can be created, this technique was proven simple and safe, and short-term clinical results were excellent: palmar hyperhidrosis was cured in 98% of patients, and axillar and plantar improvement was achieved in 62 and 65% of patients, respectively. Side-effects and complications were minor (compensatory hyperhidrosis) or self-limiting (pain). These data confirm the safety and efficacy of thoracoscopic sympathetic interventions for the treatment of EH, and support the evolution toward simplified methodologies.

Thoracoscopic sympathectomy for Buerger's disease: a report on the successful treatment of four patients

We describe herein the successful treatment of four patients with ischemic ulcers or gangrene of the fingers due to Buerger's disease by thoracoscopic sympathectomy, a new method of surgery which eliminates the difficulties associated with the traditional "open" approaches to the thoracic sympathetic chain, such as poor exposure, risk of damage to the adjacent structures, and postoperative pain. After the patients were placed in the lateral decubitus position with unilateral pulmonary ventilation, the thoracic sympathetic ganglia (T) from the lower third of T1 to T3 were resected endoscopically. The operative results were excellent, with improvement or complete resolution of the ulcer being achieved in all four patients. All of the patients were satisfied with the results in terms of ulcer healing, postoperative pain, and cosmetic appearance. Although a postoperative air leakage developed in one patient with a history of pulmonary tuberculosis, it was successfully treated with an adhesive agent. None of the patients developed Horner's syndrome. Thus, because thoracoscopic sympathectomy is easier to perform with a lower risk of complications than conventional thoracic sympathectomy, we recommend this operative approach as the procedure of choice for surgical thoracic sympathectomy.

Transthoracic endoscopic sympathectomy for hyperhidrosis and Raynaud's phenomenon

Over an 80 month period, 53 transthoracic endoscopic sympathectomies were performed in 34 patients. The indications for surgery were palmar hyperhidrosis in 20 procedures (38%), palmar and axillary hyperhidrosis in eight procedures (15%), Raynaud's phenomenon in 23 procedures (43%), and combined palmar hyperhidrosis and Raynaud's phenomenon in two procedures (4%). Follow-up data, obtained by a self-assessment postal questionnaire, was available for 47 procedures in 30 patients (91%). Fourteen out of 15 procedures (93%) performed for palmar hyperhidrosis, all eight procedures (100%) for palmar and axillary hyperhidrosis and 14 out of 22 procedures (64%) performed for Raynaud's phenomenon produced an immediate improvement in symptoms. These improvements were sustained in 13 procedures (87%) performed for palmar hyperhidrosis, all procedures performed for palmar and axillary hyperhidrosis (100%) but only 10 procedures (45%) performed for Raynaud's phenomenon at a median follow-up of 16, 34 and 44.5 months respectively. There were no deaths nor postoperative Horner's syndrome in these patients. The only minor complications were two small pneumothoraces. Compensatory sweating was observed after 24 procedures (51%). These results confirm that transthoracic endoscopic sympathectomy is a simple, safe and effective procedure. In patients with hyperhidrosis, the results are excellent and prolonged; in patients with Raynaud's phenomenon, immediate improvement can be achieved but the symptoms may return with time.

The role of sympathectomy in current surgical practice

Historically sympathectomy has been employed in the treatment of a variety of disparate disorders but in most there is little if any objective clinical evidence of its efficacy. Review of the literature confirms that sympathectomy provides an effective and permanent cure for hyperhidrosis of the hands and feet, and at present palmar hyperhidrosis is the major indication for its regular use. Sympathetic denervation of the hands is currently most easily achieved with minimal morbidity by thoracoscopic ablation of the second thoracic ganglion. Some evidence testifies to the efficacy of sympathectomy in the rare patients with true major causalgia. Clinical experience suggests that Raynaud's phenomenon in the feet can be usefully ameliorated by sympathectomy but in the hands any benefit is short lived and there is no effect on the prognosis of the disease. A weak case can be made for sympathectomy for ischaemic rest pain when arterial surgery is impractical but there is no reliable evidence to support its use in Buerger's disease, intermittent claudication, diabetic vascular disease or ischaemic ulceration or gangrene.