Resympathectomy for palmar and axillary hyperhidrosis

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.

Interventions for hyperhidrosis in secondary care: a systematic review and value-of-information analysis

BACKGROUND

Hyperhidrosis is uncontrollable excessive sweating that occurs at rest, regardless of temperature. The symptoms of hyperhidrosis can significantly affect quality of life. The management of hyperhidrosis is uncertain and variable.

OBJECTIVE

To establish the expected value of undertaking additional research to determine the most effective interventions for the management of refractory primary hyperhidrosis in secondary care.

METHODS

A systematic review and economic model, including a value-of-information (VOI) analysis. Treatments to be prescribed by dermatologists and minor surgical treatments for hyperhidrosis of the hands, feet and axillae were reviewed; as endoscopic thoracic sympathectomy (ETS) is incontestably an end-of-line treatment, it was not reviewed further. Fifteen databases (e.g. CENTRAL, PubMed and PsycINFO), conference proceedings and trial registers were searched from inception to July 2016. Systematic review methods were followed. Pairwise meta-analyses were conducted for comparisons between botulinum toxin (BTX) injections and placebo for axillary hyperhidrosis, but otherwise, owing to evidence limitations, data were synthesised narratively. A decision-analytic model assessed the cost-effectiveness and VOI of five treatments (iontophoresis, medication, BTX, curettage, ETS) in 64 different sequences for axillary hyperhidrosis only.

RESULTS AND CONCLUSIONS

Fifty studies were included in the effectiveness review: 32 randomised controlled trials (RCTs), 17 non-RCTs and one large prospective case series. Most studies were small, rated as having a high risk of bias and poorly reported. The interventions assessed in the review were iontophoresis, BTX, anticholinergic medications, curettage and newer energy-based technologies that damage the sweat gland (e.g. laser, microwave). There is moderate-quality evidence of a large statistically significant effect of BTX on axillary hyperhidrosis symptoms, compared with placebo. There was weak but consistent evidence for iontophoresis for palmar hyperhidrosis. Evidence for other interventions was of low or very low quality. For axillary hyperhidrosis cost-effectiveness results indicated that iontophoresis, BTX, medication, curettage and ETS was the most cost-effective sequence (probability 0.8), with an incremental cost-effectiveness ratio of £9304 per quality-adjusted life-year. Uncertainty associated with study bias was not reflected in the economic results. Patients and clinicians attending an end-of-project workshop were satisfied with the sequence of treatments for axillary hyperhidrosis identified as being cost-effective. All patient advisors considered that the Hyperhidrosis Quality of Life Index was superior to other tools commonly used in hyperhidrosis research for assessing quality of life.

LIMITATIONS

The evidence for the clinical effectiveness and safety of second-line treatments for primary hyperhidrosis is limited. This meant that there was insufficient evidence to draw conclusions for most interventions assessed and the cost-effectiveness analysis was restricted to hyperhidrosis of the axilla.

FUTURE WORK

Based on anecdotal evidence and inference from evidence for the axillae, participants agreed that a trial of BTX (with anaesthesia) compared with iontophoresis for palmar hyperhidrosis would be most useful. The VOI analysis indicates that further research into the effectiveness of existing medications might be worthwhile, but it is unclear that such trials are of clinical importance. Research that established a robust estimate of the annual incidence of axillary hyperhidrosis in the UK population would reduce the uncertainty in future VOI analyses.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015027803.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Evaluation of patients who underwent resympathectomy for treatment of primary hyperhidrosis

OBJECTIVES

Video thoracoscopic sympathectomy is the recommended surgical treatment for primary hyperhidrosis and has a high success rate. Despite this high success rate, some patients are unresponsive and eventually need a resympathectomy. Few studies have previously analysed exclusively the results of these resympathectomies in patients with primary hyperhidrosis. None of the studies have objectively evaluated the degree of response to surgery or the improvement in quality of life after resympathectomies.

METHODS

This is a retrospective study, evaluating 15 patients from an initial group of 2300 patients who underwent resympathectomy after failure of the primary surgical treatment. We evaluated sympathectomy levels of resection, technical difficulties, surgical complications preoperative quality of life, response to treatment and quality-of-life improvement 30 days after each surgery.

RESULTS

Regarding gender, 11 (73.3%) patients were women. The average age was 23.2 with SD of 5.17 years, and the mean body mass index was 20.9 (SD 2.12). Ten patients had major complaints about their hands (66%) and 5 (33%) patients about their forearms. A high degree of response to sympathectomy occurred in 73% of patients. In 11 of these patients, the improvement in quality of life was considered high, 3 showed a mild improvement and 1 did not improve. No major complications occurred; the presence of adhesions was reported in 11 patients and pleural drainage was necessary in 4 patients.

CONCLUSIONS

Resympathectomy is an effective procedure, and it improves the quality of life in patients with primary hyperhidrosis who failed after the first surgery.

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.

Reoperative endoscopic sympathectomy for persistent or recurrent palmar hyperhidrosis

BACKGROUND

Sympathectomy for severe palmar hyperhidrosis occasionally fails. This investigation reviews our experience with reoperative thoracoscopic sympathectomy (RS) for patients with persistent or recurrent palmar hyperhidrosis after sympathectomy.

METHODS

A retrospective analysis of patients undergoing RS for palmar hyperhidrosis was conducted. Comparison was made with all patients undergoing an initial thoracoscopic sympathectomy (TS) for palmar hyperhidrosis at our institution during the same period.

RESULTS

Over 6 years, 40 patients underwent bilateral (32) or unilateral (8) RS for refractory (35) or recurrent (5) palmar hyperhidrosis. During the same period, 321 patients underwent bilateral TS for palmar hyperhidrosis. Previous methods of sympathectomy included percutaneous ablation (25), TS (10), axillary thoracotomy (3), and a posterior transthoracic approach (2). Twenty-two RS patients and 11 TS patients required a third port to complete the procedure because of pleural adhesions (p = 0.0001). Twenty-three RS and 11 TS patients required postoperative pleural drainage (p = 0.0004). Mean length of stay was1.6 for the RS group and less than 1 day for the TS group (p = 0.0001). Alleviation of palmar hyperhidrosis occurred in 38 RS patients and 316 TS patients (p = 0.18). Compensatory sweating was identified in 21 RS patients and 101 TS patients (p = 0.01).

CONCLUSIONS

Reoperative thoracoscopic sympathectomy produced a rate of improvement comparable to that of TS. However, RS was associated with an increased need for postoperative pleural drainage, longer hospital stay, a more difficult operative procedure, and a higher rate of compensatory sweating than TS was. Reoperative sympathectomy should be considered a safe and effective option for patients with palmar hyperhidrosis who remain severely symptomatic after a sympathectomy.

Thoracoscopic and anatomic landmarks of Kuntz's nerve: implications for sympathetic surgery

BACKGROUND

Kuntz's nerves (KN) have been blamed for surgical failures of endothoracic sympathectomy. The prevalence of these fibers, however, varies between the surgical (about 10%) and anatomic literature (about 80%). This clinically orientated cadaveric study was conducted to explain this discrepancy, to reveal possible reasons for the low thoracoscopic detection rate, and to define anatomic structures as possible landmarks of KNs.

METHODS

Video-assisted thoracoscopy was performed in 33 thoracic cavities of fresh human cadavers within 48 hours postmortem, followed by anatomic dissection of the first intercostal space. Kuntz's nerves and concomitant blood vessels were of special interest. Statistical analysis included frequencies and chi(2) tests.

RESULTS

Kuntz's nerves were identified in 12.1% by thoracoscopy, whereas anatomic dissection revealed KNs in 66.7% (p = 0.003). Subpleural veins (mean diameter, 2.2 +/- 0.9 mm) parallel to KNs were found in 81.8%. No collateral arteries were identified. Diameters of KNs were 1.4 +/- 0.7 mm; distances between the first thoracic ganglion and the middle of KNs were 9.7 +/- 3.0 mm. Thoracoscopic recognition of these Kuntz veins was higher than that of KNs (62.5% vs 18.2%, p < 0.005).

CONCLUSIONS

The low thoracoscopic detection rate of KNs may be due to the low color contrast of these small fibers. They have, however, most frequently concomitant subpleural veins that are easier to detect. These veins may serve as orientation landmarks of KNs and thus contribute to a more complete denervation improving the outcome of thoracoscopic sympathectomies.

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.

Sustained benefit lasting one year from T4 instead of T3-T4 sympathectomy for isolated axillary hyperhidrosis

INTRODUCTION

Level T4 video-assisted thoracoscopic sympathectomy proved superior to T3-T4 treatment for controlling axillary hyperhidrosis at the initial and six-month follow-ups of these patients.

OBJECTIVE

To compare the results of two levels of sympathectomy (T3-T4 vs. T4) for treating axillary sudoresis over one year of follow-up.

METHODS

Sixty-four patients with axillary hyperhidrosis were randomized to denervation of T3-T4 or T4 alone and followed prospectively. All patients were examined preoperatively and were followed postoperatively for one year. Axillary hyperhidrosis treatment was evaluated, along with the presence, location, and severity of compensatory hyperhidrosis and self-reported quality of life.

RESULTS

According to patient reports after one year, all cases of axillary hyperhidrosis were successfully treated by surgery. There were no instances of treatment failure. After six months, compensatory hyperhidrosis was present in 27 patients of the T3-T4 group (87.1%) and in 16 patients of the T4 group (48.5%). After one year, all T3-T4 patients experienced some degree of compensatory hyperhidrosis, compared to only 14 patients in the T4 group (42.4%). In addition, compensatory hyperhidrosis was less severe in the T4 patients (p < 0.01). Quality of life was poor before surgery, and it improved in both groups at six months and one year of follow-up (p = 0.002). There were no cases of mortality, no significant postoperative complications, and no need for conversion to thoracotomy in either group.

CONCLUSION

Both techniques were effective for treating axillary hyperhidrosis, but the T4 group showed milder compensatory hyperhidrosis and greater patient satisfaction at the one-year follow-up.

Axillary hyperhidrosis: T3/T4 versus T4 thoracic sympathectomy in a series of 276 cases

BACKGROUND

Different techniques of video-assisted thoracic sympathectomy have been suggested to control the symptoms of axillary hyperhidrosis. We compared the results using two different levels of ganglion resection for treating axillary hyperhidrosis: T3/T4 vs. T4.

MATERIALS AND METHODS

From a group of 1119 patients operated on between July 2000 and January 2005, 276 patients with axillary hyperhidrosis were studied. The mean age was 26 (range, 13-54 years) and 61.6% were female. Of these patients, 216 (78.3%) were treated with thermal ablation of T3/T4 and 60 (21.7%) with thermal ablation of T4 alone. The procedures were bilateral and simultaneous, using two 5.5-mm trocars and 30-degree optical systems, under general anesthesia in all cases.

RESULTS

There was no mortality and no important postoperative complications or need to convert to thoracotomy in either group. The mean follow-up in the T4 group was 11 months (range, 2-23 months) and in the T3/T4 group mean follow-up was 24 months (range, 13-54 months). The immediate therapeutic success rate was 100% in both groups. There were recurrences in 7 (2.5%) patients, all from the T3/T4 group. The satisfaction rate was higher and more stable in the T4 group and compensatory sweating was lower in the T4 group.

CONCLUSION

Both techniques proved effective for controlling the axillary symptoms. Group T4 presented a higher satisfaction rate, lower recurrence rate, and lower severity of compensatory sweating.

A randomized trial of T3-T4 versus T4 sympathectomy for isolated axillary hyperhidrosis

INTRODUCTION

Video-assisted thoracic sympathectomy (VATS) is one minimally invasive definitive treatment for axillary hyperhidrosis. Different techniques exist for controlling axillary sudoresis, but they are temporary and have high cost. This study was conducted to compare the initial results from sympathectomy using two distinct levels for treating axillary sudoresis: T3-T4 vs T4.

METHODS

Sixty-two patients with axillary hyperhidrosis were prospectively randomized for denervation of T3-T4 or T4 alone. All patients were examined preoperatively and were followed-up at 1 and 6 months postoperatively. Evaluated were the axillary hyperhidrosis treatment, the presence, location, and severity of compensatory hyperhidrosis, and the quality of life.

RESULTS

All the patients said that their axillary hyperhidrosis was successfully treated by the surgery after 6 months. There was no treatment failure. Compensatory hyperhidrosis was present in 29 patients (90.6%) of the T3-T4 group and in 17 T4 patients (56.7%) after 1 month. After 6 months, all the T3-T4 patients presented some degree of compensatory hyperhidrosis vs 13 T4 patients (43.3%). The severity of the compensatory hyperhidrosis was also lower in the T4 patients (P < . 01). The quality of life was poor in both groups before the surgery, and was equally improved in both groups after 1 and 6 months of follow-up. There were no deaths or significant postoperative complications nor a need for conversion to thoracotomy.

CONCLUSION

Both techniques are effective for treating axillary hyperhidrosis, but the T4 group presented milder compensatory hyperhidrosis and had a greater satisfaction rate.

Effects of bilateral T2-sympathectomy on static and dynamic heart rate responses to exercise in hyperhidrosis patients

The static/dynamic changes of gas exchange, heart rate (HR) and blood pressure in terms of work rate (WR) and WR changes in ramp exercise were investigated by cardio-pulmonary exercise tests (CPETs) in hyperhidrosis patients before (W0), one week (W1) and four weeks (W4) after bilateral T2-sympathectomy. Accompanied by constant oxygen consumption and WR at peak exercise and similar oxygen debt in recovery, the HR significantly (p<0.05) decreased statically in all stages of CPET, but was not altered dynamically, i.e., similar slope but significantly diminished intercept in HR changes versus WR changes (70+/-6.0 vs. 82+/-19 beats/min, p<0.01), in W1 (n=11), compared to W0 (n=13). However, this surgical effect on static HR changes seemed to have disappeared in W4 (n=8), albeit at that time the static blood pressure decreased significantly during exercise. These findings suggest that bilateral T2-sympathectomy will reduce static HR without causing cardiovascular insufficiency in one week, and would then recover by one month in hyperhidrosis patients.

Changes in the sympathetic skin response after thoracoscopic sympathectomy in patients with primary palmar hyperhidrosis

OBJECTIVE

To investigate whether thoracic sympathectomy induced any change in the pattern of abnormalities or in the waveform of the sudomotor skin response (SSR) in patients with primary palmar hyperhidrosis (PPH).

METHODS

We recorded the SSR to median nerve electrical stimuli before and after bilateral thoracoscopic sympathectomy in 27 patients with PPH. We analyzed the changes in amplitude, type of waveform and pattern of abnormality.

RESULTS

All patients reported symptomatic improvement. The amplitude of the SSR decreased significantly in patients examined within 1 year after surgery, but was not different in patients examined after 1 year. The number of abnormally enhanced responses reduced after surgery, but there was no significant change in the number of patients with enhanced excitability recovery or with double-peak responses to single stimuli. There was a significant increase in the number of SSRs with a predominantly negative waveform after surgery.

CONCLUSIONS

The persistence of SSR abnormalities after surgery suggests that the central nervous system dysfunction is not modified by sympathectomy. The change of the waveform to predominantly negative type after surgery could be the consequence of the decrease in the production of sweating.

SIGNIFICANCE

Our results show the effects of sympathectomy on the SSR and on its abnormal patterns in patients with PPH.

Percutaneous CT-guided chemical thoracic sympathectomy for patients with palmar hyperhidrosis after transthoracic endoscopic sympathectomy

BACKGROUND

Palmar hyperhidrosis is a common functional disorder in the Asians. Currently, transthoracic endoscopic sympathectomy (TES) is considered to be the treatment of choice for this entity because of its high initial success rate and minimal morbidity. However, primary failure and recurrence of hyperhidrosis occurred in some patients, even with a very low incidence. We present our experience in the treatment of primary failure and recurrence of hyperhidrosis after TES by means of percutaneous computer tomography (CT) guided ethanol thoracic sympathectomy.

METHODS

From July 1999 to July 2001, 11 patients (2 males and 9 females with a mean age of 25.9 years, range: 19-44 years) of this subgroup underwent percutaneous CT-guided chemical thoracic sympathectomy. Failure of the first sympathectomy was caused by severe pleural adhesion (from the previous operative findings) in 7 patients. The remaining 4 patients were recurrent palmar hyperhidrosis. All patients underwent unilateral procedures (3 on the right and 8 on the left).

RESULTS

All patients were followed for at least 2 years after the treatment. Needle puncture was possible without difficulty in all patients. All patients had satisfactory results with minimal complication. No recurrence was noted at follow-up.

CONCLUSION

In summary, percutaneous CT-guided ethanol thoracic sympathectomy could be an easy, safe, and alternative strategy to treat patients with palmar hyperhidrosis after failure or recurrence after TES.

Anatomical basis for a successful upper limb sympathectomy in the thoracoscopic era

In this clinico-anatomical study, factors potentially responsible for unsuccessful upper limb sympathectomy (ULS) by the thoracoscopic route were evaluated. This study comprised two subsets: 1) in the clinical subset, 25 patients (n = 50 sides) underwent bilateral second thoracic ganglionectomy for palmar hyperhidrosis, and factors predisposing to unsuccessful ULS were identified; and 2) in the anatomical subset, the neural connections of the first and second intercostal spaces were bilaterally dissected in 22 adult cadavers (22 right, 21 left; n = 43 sides). Alternate neural pathways (ANP) were noted in 9 of 50 sides in the 25 clinical cases (18%). In three asthenic patients (5 sides), fascia overlying the longus colli muscle mimicked the sympathetic chain. The right superior intercostal vein (SIV) was located anterior to the second thoracic ganglion in 6 of 50 sides (12%) and predisposed to troublesome bleeding in 2 of 50 cases; the SIV was posterior to the ganglion in 19 of 50 sides (38%), posing no technical problem. On the left, the SIV was noted outside the field of dissection in all but one case. A successful outcome to sympathectomy was noted in all 25 patients. A spectrum of sympathetic contributions to the first thoracic ventral ramus for the first intercostal space was noted in 37 of 43 anatomical cases (86%). These were categorized according to the arrangements of the intrathoracic ramus between the second intercostal nerve and the first thoracic ventral ramus. The cervicothoracic ganglion (37/43 cases; 86%) and an independent inferior cervical ganglion (6/43 cases; 14%) were always located above the second rib. The second thoracic ganglion was consistently located in the second intercostal space. This study demonstrates that ANPs have little clinical significance when a second thoracic ganglionectomy is undertaken. Technical failures may be avoided if the surgeon is mindful of anatomical variations at surgery.

Endoscopic transthoracic sympathectomy for upper limb hyperhidrosis: limited sympathectomy does not reduce postoperative compensatory sweating

OBJECTIVE

Compensatory sweating is the most common and troublesome complication of thoracodorsal sympathectomy. Whether the magnitude of compensatory sweating is related to the extent of sympathectomy is unclear. We investigated the association between the extent of sympathectomy and the occurrence and severity of compensatory sweating after endoscopic transthoracic sympathectomy for upper limb hyperhidrosis.

METHODS

From September 1992 to June 2000, data from patients undergoing thoracoscopic sympathectomy to treat primary upper limb hyperhidrosis in our department were prospectively collected. Routine follow-up with clinical examination was performed at 1, 3, and 6 months for the first postoperative year and every year thereafter. Late follow-up (February 2001) was with a standardized questionnaire by mail or telephone concerning compensatory sweating and patient satisfaction. Associations between the extent of sympathectomy and the occurrence and severity of compensatory sweating were analyzed with logistic regression and adjusted for age, gender, and relevant confounding factors.

RESULTS

Two hundred sixty-eight sympathectomies were consecutively performed in 134 patients (99 female, 35 male; mean age, 27.8 +/- 6.7 years). In the 84 patients with palmar hyperhidrosis, eight underwent T1-T2 resection, four T1-T3 resection, eight T2-T3 resection, and 64 T2-T4 resection. In the 43 patients with palmar and axillary hyperhidrosis, eight underwent T1-T5 resection and 35 T2-T5 resection. The seven patients with isolated axillary hyperhidrosis underwent T3-T5 sympathectomy. No deaths occurred; one conversion for bleeding, one permanent Horner's syndrome, and six minor complications did occur. The initial cure rate was 99.2%. The initial satisfaction rate was 97%. The mean follow-up period was 44.3 months (range, 7 to 100 months), and complete follow-up was available in 132 patients (98.5%). Ninety-five patients (71.9%) had compensatory sweating develop. Seventy patients (53%) judged their compensatory sweating to be minor and intermittent, and 25 patients (19%) judged it severe (16% embarrassing, 3% disabling). On univariate and multivariate analysis, the extent of denervation was not associated with the occurrence or the severity of compensatory sweating. The late satisfaction rate was 91.5%. Compensatory sweating and temporary relief/recurrence were equally considered to be the main causes of dissatisfaction.

CONCLUSION

Compensatory sweating was the most common long-term complication of thoracodorsal sympathectomy for primary hyperhidrosis. Its incidence and severity were not associated with the extent of sympathectomy.

Endoscopic thoracic sympathectomy for hyperhidrosis: experience with both cauterization and clamping methods

The goal was to review results of sympathectomy, performed with use of either cauterization or clamping, in patients with hyperhidrosis (n = 1,312): 653 early patients undergoing electrocautery sympathectomy, 305 later patients undergoing cauterization, and 354 patients treated with a clamping procedure. Patients were interviewed by telephone about the status of symptoms, adverse outcomes, and satisfaction. Palmar hyperhidrosis was cured in all but one patient, with a 98% satisfaction rate in the clamping group and 94.3% and 95.1% in the two cauterization groups ( < or = 0.025, clamping > cauterization). Facial sweating or blushing was cured in the majority (88%) of the 301 patients reporting this symptom. Severe compensatory hidrosis occurred in less than 6% (3% of the clamping group; < or = 0.001, clamping < cauterization). Recurrence rate was 3.0%. A number of factors were related to outcome. Endoscopic thoracic sympathectomy with clamping appears to be at least as safe and effective as earlier cauterization techniques, with the potential advantage of reversibility in those patients unhappy with the outcome.

Video-assisted thoracoscopic "resympathicotomy" for palmar hyperhidrosis: analysis of 42 cases

BACKGROUND

There are rare reports of video-assisted thoracoscopic resympathicotomy for patients with palmar hyperhidrosis. I present our experience in treating a persistent or recurrent palmar hyperhidrosis after primary endoscopic sympathectomy or sympathicotomy and discuss the perioperative management.

METHODS

We reoperated on 42 patients using a technique of video-assisted thoracoscopic resympathicotomy. All patients were placed in a semi-sitting position under single- or double-lumen intubated anesthesia. An 8-mm, 0 degrees thoracoscope was used to interrupt the nerve conduction to the palms from the T2 and T3 ganglia, through one or two 0.8-cm subaxillary incisions.

RESULTS

The reasons for failure of endoscopic sympathectomy or sympathicotomy in 26 patients included pleural adhesion (15 of 26, 57.7%), incorrect identification of T2 ganglion (3 of 26, 11.5%), vessel overriding or close to sympathetic nerve (3 of 26, 11.5%), incomplete interruption of sympathetic nerve (2 of 26, 7.7%), medially located sympathetic nerve (2 of 26, 7.7%), and aberrant venous arch (1 of 26, 3.8%). The causes of recurrent palmar hyperhidrosis after primary transthoracic endoscopic sympathicotomy or sympathectomy (TES) in 16 patients included a possible effect of T3 ganglion (8 of 16, 50%), Kuntz fiber (3 of 16, 18.8%), nerve regeneration (3 of 16, 18.8%), and incomplete interruption of T2 ganglion (2 of 16, 12.5%). Surgical complications included pneumothorax (1 patient, 2.4%), hemothorax (1 patient, 2.4%), and compensatory sweating (36 patients, 86%). All patients had obtained successful bilateral sympathectomies and had satisfactory results after a mean of 32.1 months of follow-up.

CONCLUSIONS

Video-assisted thoracoscopic resympathicotomy is an effective and safe method for a previously unsuccessful sympathectomy or recurrent palmar hyperhidrosis if the surgeon acknowledges possible anatomic variations and can overcome the problems related to pleural adhesions.