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

CT-assisted thoracic sympathicolysis for therapy of primary hyperhidrosis palmaris-retrospective analysis of the influence of the amount and position of the sympathetic agent on the therapeutic outcome and side effects

PURPOSE

 The objective of the present study was to evaluate the benefit of a thoracic, computed tomography-guided sympathicolysis (CTSy) in patients with primary, focal hyperhidrosis of the hands. In addition, the influence of the amount and distribution of the administered sympathicolytic agent was to be assessed.

PATIENTS AND METHODS

 Retrospectively, 78 patients [13 (16.7 %) men, mean age 31.2 ± 9 years and 65 (83.3 %) women, mean age 34.2 ± 12 years], who had been treated using CTSy, were included in the study. The indication for treatment was primary focal palmar hyperhidrosis grade II and grade III after exhaustion of all conservative treatment options and a continued high level of suffering. CTSy was performed after establishing the entry plane at the level of the intervertebral space T2 / T3 via a dorsolateral approach using a 22-G coaxial needle. On average 5 (2-10) ml of a sympathicolytic mixture (10 ml consisting of 8 ml 96 % alcohol, 1.6 ml 0.5 % Carbostesin and 0.4 ml 0.9 % NaCl solution, with added amounts of contrast medium) were instilled. The volume of distribution of the sympathicolytic agent was determined in craniocaudal direction using CT images. The patients evaluated their sense of discomfort preinterventionally, 2 days postinterventionally, and 6 and 12 months after the intervention, on the basis of a Dermatology life Quality Index (DLQI) as well as the side effects that occurred.

RESULTS

 The technical success rate of CTSy was 100 %. No major complications occurred. The interventions performed led to a significant reduction (p < 0.001) in the preinterventional sense of discomfort 2 days, 6 and 12 months after CTSy. As the most common side effect, compensatory sweating was reported by 16/78 (20.5 %) of the patients over the further course. In all of these patients, the volume of sympathicolytic agent administered was below 5 ml. In no case did the sympathicolytic agent extend caudally beyond the base plate of Th 3. No compensatory sweating of the back was observed in 5/78 (6.4 %) patients; here the sympathicolytic volume was above 5 ml and extended significantly caudally below the baseplate of T3.Transient miosis and ptosis was found in 8/78 (10.3 %) patients. In all of these patients, the volume of sympathicolytic agent administered was above 5 ml and it extended markedly cranially beyond the upper plate of T2. A mild to moderate recurrent sweating developed in 35/78 (44.9 %) patients, which was more marked if the volume of sympathicolytic administered was below 5 ml and slightly more pronounced on the left than on the right. Given a high level of satisfaction overall, 71/78 (91.0 %) patients said that they would undergo the intervention again.

CONCLUSION

 For patients with primary, focal palmar hyperhidrosis CTSy represents a therapeutic option that offers good benefit and has few side effects. The amount and spatial distribution of the sympathicolytic agent has an influence on the therapeutic outcome and the side effects.

KEY POINTS

· CT-assisted thoracic sympathicolysis is a minimally invasive, low-complication therapy for treatment of severe forms of primary hyperhidrosis palmaris.. · CT-assisted thoracic sympathicolysis can usually be performed on an outpatient basis.. · The quantity and local distribution of the sympathicolytic agent has an influence on the therapeutic outcome and the side effects..

CITATION FORMAT

· Andresen J, Scheer F, Schlöricke E et al. CT-assisted thoracic sympathicolysis for therapy of primary hyperhidrosis palmaris-retrospective analysis of the influence of the amount and position of the sympathetic agent on the therapeutic outcome and side effects. Fortschr Röntgenstr 2021; 193: 574 - 581.

Advanced medical interventions in pleural disease

The burden of a number of pleural diseases continues to increase internationally. Although many pleural procedures have historically been the domain of interventional radiologists or thoracic surgeons, in recent years, there has been a marked expansion in the techniques available to the pulmonologist. This has been due in part to both technological advancements and a greater recognition that pleural disease is an important subspecialty of respiratory medicine. This article summarises the important literature relating to a number of advanced pleural interventions, including medical thoracoscopy, the insertion and use of indwelling pleural catheters, pleural manometry, point-of-care thoracic ultrasound, and image-guided closed pleural biopsy. We also aim to inform the reader regarding the latest updates to more established procedures such as chemical pleurodesis, thoracentesis and the management of chest drains, drawing on contemporary data from recent randomised trials. Finally, we shall look to explore the challenges faced by those practicing pleural medicine, especially relating to training, as well as possible future directions for the use and expansion of advanced medical interventions in pleural disease.

Unilateral sequential endoscopic thoracic sympathectomy for palmar hyperhidrosis: a proposed technique to overcome compensatory hyperhidrosis and improve plantar hyperhidrosis

BACKGROUND

Although endoscopic thoracic sympathectomy (ETS) offers permanent cure of palmar hyperhidrosis (PH), compensatory hyperhidrosis (CH) often complicates the procedure. We analyzed the outcomes of a 2-month interval for unilateral sequential ETS (S-ETS) in comparison with simultaneous bilateral ETS (B-ETS), notably regarding CH and associated plantar hyperhidrosis, in treating patients with PH.

PATIENTS AND METHODS

Four hundred seven patients with intractable PH were randomly assigned into two groups: the B-ETS group (204 patients) and the S-ETS group (203 patients).

RESULTS

Three hundred sixty-four patients completed the study. Complication rates were comparable for both groups. No patient died perioperatively, and no conversion was necessary. Treatment success on follow-up was 97.2% for S-ETS and 96.7% for B-ETS. The incidence of CH was decreased substantially from 131 (71.1%) patients in the B-ETS group to 22 (12.2%) patients in the S-ETS group (P<.001), with no patient suffering severe CH in the S-ETS group compared with 33 (25.5%) patients in the B-ETS group. Eighty-four (58.3%) patients in the S-ETS group had simultaneous disappearance or decreased perspiration on the soles. All patients in the S-ETS group were satisfied, whereas 37.9% of B-ETS patients were unsatisfied with their operation, mostly because of CH and recurrences.

CONCLUSIONS

Although both sympathectomies were effective, safe, and minimally invasive methods for treatment of PH, unilateral sequential ETS appeared to be a more optimal technique in terms of reduction of CH to a minimum and improvement of associated plantar hyperhidrosis.

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.

Pleuroscopy in 2013

Pleuroscopy provides a window to the pleural space while enabling biopsy of the parietal pleura under direct visual guidance for effusions of unknown etiology, guided chest tube placement, and pleurodesis for recurrent pleural effusions or pneumothoraces in selected patients. The procedure enjoyed resurgence when thoracic surgeons introduced the technique for video-assisted thoracic surgery (VATS). VATS is performed under general anesthesia with single-lung ventilation; pleuroscopy is performed in an endoscopy suite using nondisposable rigid or flex-rigid instruments, local anesthesia, and conscious sedation. Pleuroscopy is less invasive; in this review, we discuss the indications, complications, techniques, and recent advances in the procedure.

Sympathetic nerve reconstruction for compensatory hyperhidrosis after sympathetic surgery for primary hyperhidrosis

We performed sympathetic nerve reconstruction using intercostal nerve in patients with severe compensatory hyperhidrosis after sympathetic surgery for primary hyperhidrosis, and analyzed the surgical results. From February 2004 to August 2007, sympathetic nerve reconstruction using intercostal nerve was performed in 19 patients. The subjected patients presented severe compensatory hyperhidrosis after thoracoscopic sympathetic surgery for primary hyperhidrosis. Reconstruction of sympathetic nerve was performed by thoracoscopic surgery except in 1 patient with severe pleural adhesion. The median interval between the initial sympathetic surgery and sympathetic nerve reconstruction was 47.2 (range: 3.5-110.7) months. Compensatory sweating after the reconstruction surgery improved in 9 patients, and 3 out of them had markedly improved symptoms. Sympathetic nerve reconstruction using intercostal nerve may be one of the useful surgical options for severe compensatory hyperhidrosis following sympathetic surgery for primary hyperhidrosis.

Current status of medical pleuroscopy

Medical pleuroscopy (MP) offers a safe and minimally invasive tool for interventional pulmonologists. It allows diagnosis of unexplained effusion, while at the same time allowing drainage and pleurodesis. It can also help in the diagnosis of diffuse interstitial disease or associated peripheral lung abnormality in the presence of effusion. It can have a therapeutic role in pneumothorax and hyperhidrosis or chronic pancreatic pain. This article reviews the technical aspects and range of applications of MP.

Thoracoscopic sympathectomy for palmar and axillary hyperhidrosis: four-year outcome and quality of life after bilateral 5-mm dual port approach

BACKGROUND

During recent years, thoracoscopic sympathectomy has been the standard treatment for hyperhidrosis. Different surgical techniques have been described without proving their advantages compared with other procedures. This study was designed to evaluate our modification of thoracoscopic sympathectomy and to compare the effectiveness between axillary and palmar hyperhidrosis.

METHODS

Ninety patients with axillary or palmar hyperhidrosis who underwent bilateral thoracoscopic sympathectomy with single-lumen ventilation with a dual 5-mm port approach were followed up for a median of 3.9 (range, 1-6) years. The clinical course and data during the hospitalization and consultation in our outpatient clinic were reviewed. The following parameters were evaluated: clinical improvement, satisfaction, changes in quality of life, and compensatory sweating and gustatory sweating.

RESULTS

The perioperative mortality was 0, and the morbidity was 6.5%. In 81% clinical improvement of sweating was noticed; 55% did not sweat at all. A total of 88% of patients were satisfied with the result of the operation. The rates of compensatory sweating and gustatory sweating were 93.5% and 49.4%, respectively. The result of sympathectomy in patients with palmar hyperhidrosis were significantly better concerning rate of satisfaction (p = 0.006) and improvement of symptoms (p = 0.027) compared with patients with axillary symptoms. Additionally it was found that the compensatory sweating had significantly impacted the satisfaction rating of the operation.

CONCLUSION

Currently different effective surgical approaches for the treatment of hyperhidrosis with improvement rates of more than 80% are available. The quality of the intervention has to be evaluated by changes in quality of life and intensity of compensatory sweating. Thoracoscopic sympathectomy as performed in our institution offers results and complications comparable to previously published trials; however, because of single-lumen ventilation the management is much easier. Therefore, this technique offers an interesting option for the treatment of patients with palmar and axillary hyperhidrosis.

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.

Phantom sweating: a novel autonomic paresthesia

OBJECTIVE

To describe the biology of phantom sweating, a novel autonomic neuropathy symptom, based on a description of a patient with a small fiber and autonomic neuropathy.

METHODS

Clinical and laboratory assessments.

RESULTS

Evidence of a generalized small fiber and autonomic neuropathy.

INTERPRETATION

Phantom sweating occurs frequently after sympathectomy but has not been reported previously in patients with a somatosensory or autonomic neuropathy. We suggest that this symptom is an autonomic paresthesia.

The Prevalence of Blebs or Bullae Among Young Healthy Adults

BACKGROUND

To determine the prevalence of blebs or bullae using thoracoscopy in young healthy adults, and to compare patient characteristics among those with and without blebs.

METHODS

Bilateral thoracoscopic evaluation of the lungs was performed in healthy individuals who were referred for thoracoscopic thoracic sympathectomy for essential hyperhidrosis. Participants were enrolled into a registry and followed for up to 9 years.

RESULTS

Analysis was performed on 250 consecutive cases. Blebs were observed in 15 of 250 individuals (6%; male, n = 6; female, n = 9; mean age, 25.3 years; range, 15 to 51 years). Individuals with blebs had a significantly lower body mass index (BMI) [mean +/- SD, 20.7 +/- 2.4 kg/m(2) vs 22.7 +/- 3.4 kg/m(2); p = 0.027] when compared to individuals without blebs, whereas all other parameters were similar. Blebs were most prevalent among slim individuals (BMI < 22 kg/m(2)) who smoked (odds ratio, 5.9; 95% confidence interval, 1.19 to 29.20).

CONCLUSION

Blebs were identified thoracoscopically in 6% of young healthy adults with no underlying lung disease. Low BMI in combination with smoking may have an important role in the development of pleural blebs in healthy young adults; however, these changes may not be responsible for future spontaneous pneumothoraces.

Effectiveness and safety of endoscopic thoracic sympathectomy for excessive sweating and facial blushing: A systematic review

Objectives:Despite controversies, endoscopic thoracic sympathectomy (ETS) has been used as a treatment for excessive sweating of hands and face and for facial blushing. This study aims to evaluate the effectiveness of ETS for the current indications in a systematic review.

Methods:Controlled clinical trials and cohort studies with more than 100 patients were included. Abstracts were searched from MEDLINE and CCTR from 1966 to June 2004. Two reviewers extracted the data and assessed study quality. Data on effectiveness and safety were synthesized qualitatively.

Results:We did not find any controlled clinical trials. Fifteen prospective studies were included. The internal and external quality of these studies were poor overall. Follow-up was commonly less than 2 years, during which time excessive sweating and facial blushing seemed to decrease among most patients. Immediate complications related to thoracoscopy occurred in up to 10 percent of patients. Compensatory sweating below breast level was reported in up to 90 percent of the patients. Other common side effects included dryness of face and hands, gustatory sweating, and neuralgic pain. Several other less common side effects were reported.

Conclusions:The evidence of the effectiveness of ETS is weak due to a lack of randomized trials. The intervention leads to severe immediate complications in some of the patients, and to persistent side-effects for many of the patients.

Sympathectomy for hyperhidrosis: should we place the clamps at T2–T3 or T3–T4?

Endoscopic thoracic sympathectomy is routinely used to treat severe hyperhidrosis. It is usually performed at the T2-T3 level of the nerve, but may produce less severe compensatory hidrosis if performed at a lower level. This study evaluates the outcome of 1,274 patients who underwent endoscopic thoracic sympathectomy for plamar, plantar, axillary or facial hyperhidrosis/blushing. Half of the patients were clamped at the T2-T3 level and half were clamped at the T3-T4 level. Postsurgical symptoms and side effects were assessed by interview. All of patients with palmar hyperhidrosis were cured or improved. Patients with plantar and axillary hyperhidrosis were more likely to be improved at T3-T4 level clamping. Patients with facial hyperhidrosis were more likely to be cured at T2-T3 level, but did show improvement at the T3-T4 level. Overall satisfaction was higher in the T3-T4 group. Some degree of mild compensatory sweating occurred in all patients. However, severe compensatory sweating was more common in the T2-T3 group. Around 2% of patients requested a reversal of their surgery. Endoscopic thoracic sympathectomy is a safe and effective treatment for hyperhidrosis. Clamping at the T3-T4 level has a more successful outcome. In particular, it appears to reduce the incidence of severe compensatory hidrosis.

Fluorescein-enhanced autofluorescence thoracoscopy in patients with primary spontaneous pneumothorax and normal subjects

RATIONALE

The exact site(s) and pathophysiology of air leakage in patients with primary spontaneous pneumothorax (PSP) are unknown. In one patient with PSP, fluorescein-enhanced autofluorescence thoracoscopy (FEAT) has shown areas of parenchymal abnormality unnoticed during white light thoracoscopy (WLT).

OBJECTIVES

To prospectively perform and compare WLT and FEAT in patients with spontaneous pneumothorax and in normal subjects.

METHODS

One-time FEAT and WLT inspection with systematic mapping of semiquantified lesions in 12 consecutive patients with PSP was compared with one-time FEAT and WLT during sequential bilateral thoracoscopy in 17 control subjects.

RESULTS

WLT abnormalities (anthracosis, cobblestone malformation, and blebs/bullae) were more prevalent in PSP. FEAT, however, showed high-grade lesions in PSP only, which often were present at areas that were normal, or that only showed anthracosis at WLT. When blebs/bullae were present, bleb-associated FEAT abnormalities were only present in two. Actual fluorescein leakage was seen in two patients with PSP.

CONCLUSIONS

Lungs in patients with PSP show significantly more abnormalities at WLT when compared with normal subjects. High-grade FEAT lesions were exclusively present in PSP, and predominantly at lung zones that appeared normal at white light inspection. These findings suggest that significant parenchymal abnormalities are not limited to lesions visible during WLT, such as blebs and bullae.

[Primary hyperhidrosis and anxiety: a prospective preoperative survey of 158 patients]

OBJECTIVE

To determine the location of hyperhidrosis, the accompanying signs and symptoms, and patient anxiety assessed on 2 scales and standardized psychometric instruments.

PATIENTS AND METHODS

A prospective study of patients with hyperhidrosis was carried out between September 1, 2001 and June 30, 2003 with a self-administered preoperative questionnaire. The variables studied included the location of hyperhidrosis, the accompanying signs and symptoms, and the self-reported degree of anxiety and perception of its effect on daily life assessed by the State-Trait Anxiety Inventory (STAI) and a questionnaire designed in our department.

RESULTS

Palmar hyperhidrosis was reported by 93.6% of patients, plantar by 70.2%, axillary by 66.4%, facial by 12.1%, groin by 8.2%, chest by 5%, and abdominal by 2%. While more than 50% of the patients reported facial blushing and palpitations as accompanying signs and symptoms, approximately 30% experienced epigastric pain, trembling, and headaches. Over half of the patients reported that their anxiety was incapacitating, and a mere 1.2% experienced none at all. STAI scores were similar to those of the general population whereas scores on our department's questionnaire reflected those of the self-reported anxiety ratings.

CONCLUSIONS

Primary hyperhidrosis is a disorder in which excessive sweating occurs mainly, but not exclusively, on the palms. The condition is accompanied by signs and symptoms typical of autonomic nervous system hyperactivity and by a degree of anxiety that has an incapacitating effect on normal life, although that anxiety is not detected by the STAI questionnaire alone.

Normal volume and cellular contents of pleural fluid

Because of the technical difficulties in obtaining a-traumatical access to the normal pleural space, the exact volume and cellular content of normal pleural fluid in humans were still unknown until very recently, and animal-derived extrapolation data had to be used. After having developed a minimally invasive thoracoscopic technique for performing sympathectomy in patients suffering from essential hyperhidrosis, but with otherwise absence of thoracic disease, we have been able to achieve minimally traumatic access to normal pleural spaces. Using pleural lavage, a technique consisting of injection and immediate aspiration of 150 mL of prewarmed saline into the pleural space, we were able to determine the total and differential cell content of the few milliliters of original pleural fluid. The exact volume of this original pleural fluid could be measured using urea as an endogenous marker of dilution. Expressed per kilogram of body mass, total pleural fluid volume in healthy, non-smoking humans was 0.26+/-0.1 mL kg(-1). Total white blood cell count (after correction for dilution) was 1.716 x 10(3) cells mL(-1). Differential cell counts yielded median 75% (IR 16%) macrophages, 23% (IR 18%) lymphocytes, and marginally present mesothelial cells (1%, IR 2%), neutrophils (0%, IR 1%) and eosinophils (0%, IR 0%). There was no significant correlation between age and pleural lavage results in a study population aged 17 to 54 years old, which suggests that these results may be extrapolated to the situation in children and adolescents.

Management of primary hyperhidrosis: a summary of the different treatment modalities

Hyperhidrosis is a common and distressing condition involving increased production of sweat. A variety of treatment modalities are used to try to control or reduce sweating. Sweat is secreted by eccrine glands innervated by cholinergic fibers from the sympathetic nervous system. Primary hyperhidrosis most commonly affects palms, axillae and soles. Secondary hyperhidrosis is caused by an underlying condition, and treatment involves the removal or control of this condition. The treatment options for primary hyperhidrosis involve a range of topical or systemic medications, psychotherapy and surgical or non-surgical invasive techniques. Topical antiperspirants are quick and easy to apply but they can cause skin irritation and have a short half life. Systemic medications, in particular anticholinergics, reduce sweating but the dose required to control sweating can cause significant adverse effects, thus, limiting the medications' effectiveness. Iontophoresis is a simple and well tolerated method for the treatment of hyperhidrosis without long-term adverse effects; however, long-term maintenance treatments are required to keep patients symptom free. Botulinum toxin A has emerged as a treatment for hyperhidrosis over the past 5-6 years with studies showing good results. Unfortunately, botulinum toxin A is not a permanent solution, and patients require repeat injections every 6-8 months to maintain benefits. Psychotherapy has been beneficial in a small number of cases. Percutaneous computed tomography-guided phenol sympathicolysis achieved good results but has a high long-term failure rate. Surgery has also been shown to successfully reduce hyperhidrosis but, like other therapies, has several complications and patients need to be informed of these prior to undergoing surgery. The excision of axillary sweat glands can cause unsightly scarring and transthoracic sympathectomy (either open or endoscopic) can be associated with complications of compensatory and gustatory hyperhidrosis, Horner syndrome and neuralgia, some of which patients may find worse than the condition itself.

Thoracoscopic sympathectomy in the management of vasomotor disturbances and complex regional pain syndrome of the hand

Complex regional pain syndrome, vasospastic disorders, and hyperhidrosis are chronic and debilitating upper extremity problems. Twenty-nine consecutive patients treated with thoracoscopic sympathectomy are presented. Diagnoses included complex regional pain syndrome, hyperhidrosis, Buerger's disease, Raynaud's disease, and peripheral vascular disease. All patients with hyperhidrosis had complete symptom resolution. Patients with Buerger's and Raynaud's disease had excellent/good results. Six patients with complex regional pain syndrome had excellent or good relief; the remaining six patients had varying degrees of recurrence. A statistically significant association was noted between duration of complex regional pain syndrome prior to sympathectomy and outcome. Thoracoscopic sympathectomy is an effective treatment for hyperhidrosis and vasospastic disorders. Although the results for complex regional pain syndrome are not uniformly excellent, this technique offers promise in the treatment of this difficult problem.

[Primary hyperhidrosis: prospective study in 338 patients]

BACKGROUND AND OBJECTIVE

The objective of this report is to study the clinical aspects of the patients with primary hyperhidrosis (PH) and the social and occupational distressing condition.

PATIENTS AND METHOD

From January 1998 to October 2002, 338 patients with PH completed a preoperative questionnaire to register: age, gender, profession, associated diseases, familiar hyperhidrosis history, sweating location, associated dermatological lesions and social embarrassesment. 179 patients were asked about their general symptomatology.

RESULTS

In 86% of the patients PH started during infancy, 71.5% were female (mean age 28.8 years). A few patients had others diseases and 42.5% had some associated dermatological lesions. In 47.9% of the patients there is family history of PH. 96.4% reported palmar hyperhidrosis, 80.7% plantar PH and 71.3% reported axillary PH, being less frequent in others regions of the body. The most frequent clinical founding associated is facial blushing in 60.3%, 52.3% heart palpitations, 48% muscle stress, 31.8% reported trembling of the hands and 30,8% headache. In reference to social embarrassesment, we observe that relations between friends and professional environment are the most problematic situation.

CONCLUSIONS

PH is a pathologic condition starting in infancy, family history of PH is frequent and most patients have some associated dermatological lesions. Excessive sweating is especially common in palms but no exclusively of this region as it extends to others regions with the same intensity. It can be associated with symptomatology suggestive of hyperexcitability of the sympathetic activity like facial blushing, trembling or headache, symptoms difficult to consider whether they are cause or consequence.

State of the art in thoracospic surgery: a personal experience of 2000 videothoracoscopic procedures and an overview of the literature

BACKGROUND

Herein we compare our personal experience with a series of > 2000 videothoracoscopic procedures with those reported in the literature to identify the procedures now accepted as the gold standard, those still regarded as investigational, and those considered unacceptable.

METHODS

Between June 1991 and December 2000, we performed 2068 videothoracoscopic procedures, including lung cancer staging (n = 910), wedge resections (n = 261), lobectomies (n = 221), pneumonectomies (n = 6), the diagnosis and treatment of pleural diseases (n = 200), the treatment of pneumothorax (n = 170), giant bullae (n = 57), lung volume reduction surgery (LVRS) for emphysema (n = 41), the diagnosis and treatment of mediastinal diseases (n = 133), the treatment of esophageal diseases (n = 39), and 30 other miscellaneous procedures.

RESULTS

A review of the literature indicates that videothoracoscopy is usually considered the preferred approach for the treatment of spontaneous pneumothorax, the diagnosis of indeterminate pleural effusions, the treatment of malignant pleural effusions, sympathectomy, and the diagnosis and treatment of benign esophageal or mediastinal diseases. The videoendoscopic approach to LVRS for emphysema is still under evaluation. Videothoracoscopic wedge resections for the diagnosis of indeterminate nodules and the treatment of primary lung cancer, metastases, and other malignancies are still controversial due to oncologic concerns. Videoendoscopic major pulmonary resections are usually considered investigational or even unacceptable due to oncologic concerns, technical difficulties, and the risk of complications.

CONCLUSIONS

Although we generally agree with the foregoing recommendations, we consider videoendoscopy the best approach for LVRS and particularly useful for the staging of lung cancer, where we always perform it as the first step of the operation. We widely perform videoendoscopic major pulmonary resections, but we believe that these procedures should only be used in strictly selected cases and at specialized centers.

Anatomic variations of the T2 nerve root (including the nerve of Kuntz) and their implications for sympathectomy

OBJECTIVE

The aim of this study was to clarify the anatomic variations of the intrathoracic nerve of Kuntz, and this should help delineate the resection margins during video-assisted thoracic sympathectomy.

METHODS

Sixty-six thoracic sympathetic chains of 39 adult Korean cadavers were dissected on both sides of the thorax in 27 cadavers (54 sides) and on one side in 12 cadavers (12 sides).

RESULTS

The intrathoracic nerve was observed in 45 (68.2%) sides and was present bilaterally in 48.1% of cadavers. No intrathoracic nerve or ascending ramus communicans arising from the second thoracic nerve was observed in only 5 (7.6%) sides. The diameter of the intrathoracic nerve was 1.25 plus minus 0.55 mm on average. The arising point of the intrathoracic nerve from the second thoracic nerve was 7.3 mm on average from the sympathetic trunk. Presence of the stellate ganglion was noted in 56 (84.8%) sides, and 6 (9.1%) sides showed a single large ganglion formed by the stellate and the second thoracic sympathetic ganglia. The second thoracic sympathetic ganglion was most commonly located (50%) in the second intercostal space.

CONCLUSION

The anatomic variations of the intrathoracic nerve of Kuntz and the second thoracic sympathetic ganglion were characterized in human cadavers. It is hoped that this study will help to improve the recurrence of symptoms caused by the intrathoracic nerve in an upper thoracic sympathectomy for hyperhidrosis.

Biportal thoracoscopic sympathectomy: surgical techniques and clinical results for the treatment of hyperhidrosis

OBJECTIVE

To describe a bilateral thoracoscopic sympathectomy procedure, using a biportal approach, for the treatment of severe hyperhidrosis.

METHODS

Between May 1996 and September 2000, 103 consecutive patients underwent thoracoscopic sympathectomy procedures to treat bilateral hyperhidrosis (206 procedures). Operative results, complications, and patient satisfaction were determined by reviews of hospital and office charts and by follow-up assessments in the outpatient clinic. Long-term results were determined with clinical examinations, follow-up office visits, and follow-up questionnaires.

RESULTS

Ninety-three patients presented with primary palmar hyperhidrosis, eight with primary axillary hyperhidrosis, and two with primary craniofacial hyperhidrosis. Rates of complete resolution in the primary area affected were 100% in palmar and craniofacial cases and 75% in axillary cases. The average length of hospitalization was 1.06 days, and 96 patients (93.2%) were discharged on or before the end of the first postoperative day. Of 59 patients (57.3%) who developed compensatory hyperhidrosis, only 11 patients (10.7%) reported that it was bothersome and none considered it disabling. All postoperative complications were transient; five patients experienced unilateral Horner's syndrome, three patients experienced intercostal neuralgia, and two patients required a chest tube after surgery because of a pneumothorax.

CONCLUSION

Thoracoscopic sympathectomy using a biportal approach effectively treats hyperhidrosis and is associated with short hospital stays, high patient satisfaction rates, and low rates of compensatory hyperhidrosis or other complications.

The efficacy of intraoperative internal intercostal nerve block during video-assisted thoracic surgery on postoperative pain

BACKGROUND

Video-assisted thoracic surgery (VATS) is widely used for many thoracic surgical procedures. Post-operative pain is less after VATS than after conventional thoracic surgery, but is still significant. The objective of this study was to assess the efficacy of thoracoscopic, internal intercostal nerve block in alleviating immediate postoperative pain.

METHODS

Thirty-two patients underwent VATS bilateral sympathectomy for the treatment of hyperhidrosis. The patients were randomly divided into two groups with similar demographic and preoperative physiologic parameters. Group A (n = 16) was submitted to thoracoscopic, internal intercostal nerve blocks performed at T2, T3, and T4 intercostal levels using 3 cc of 0.5% bupivacain in each intercostal space. The injections were performed bilaterally, immediately after the sympathectomy, through the same port. Group B (n = 16) underwent bilateral thoracic sympathectomy without the block. During the immediate postoperative period, heart rate, blood pressure, respiratory rate, pain score, and analgesic requirements were monitored every 30 minutes.

RESULTS

No morbidity was recorded in association with the thoracoscopic, internal intercostal nerve block. The mean heart rates (77 +/- 6 vs 89 +/- 12 beats per minute, p < 0.001), respiratory rates (15 +/- 2 vs 18 +/- 3 respirations per minute, p < 0.01), pain score (1.9 +/- 0.6 vs 2.7 +/- 0.5, p < 0.01), and postoperative analgesic requirements (20 +/- 18 vs 50 +/- 21 mg pethidine HCL, p < 0.001) were significantly lower in group A. There was no significant difference in blood pressures.

CONCLUSIONS

Thoracoscopic, internal intercostal nerve block with bupivacain 0.5% during VATS is safe and effectively reduced the immediate postoperative pain and analgesic requirements.

Volume and cellular content of normal pleural fluid in humans examined by pleural lavage

Currently, no reliable data are available on the volume or on the cellular content of pleural fluid in normal humans. In analogy with bronchoalveolar lavage (a technique enabling retrieval of small volumes of epithelial lining fluid from the lung), we developed a pleural lavage (PL) technique consisting of injection and retrieval of 150 ml of saline into the right pleural space, performed during a thoracoscopic sympathicolysis procedure in otherwise healthy subjects suffering from essential hyperhidrosis. With urea used as an endogenous marker of dilution, measured mean right-sided pleural fluid volume was 8.4 +/- 4.3 ml. In a subgroup of subjects, we confirmed that right- and left-sided pleural fluid volumes were similar. Expressed per kilogram of body mass, total pleural fluid volume in normal, nonsmoking humans is 0.26 +/- 0.1 ml/kg. Total cell count in the PL fluid of nonsmoking normal subjects yielded a median of 91 x 10(3) white blood cells (WBC) per milliliter of lavage fluid (interquartile range [IR] = 124 x 10(3) cells/ml). Taking into account a measured dilution factor of 18.86, the total WBC count in the original pleural fluid was 1,716 x 10(3) cells/ml. Differential cell counts yielded a predominance of macrophages (median: 75%; IR: 16%) and lymphocytes (median: 23%; IR: 18%). Mesothelial cells (median: 1%; IR: 2%), neutrophils (median: 0%; IR: 1%), and eosinophils (median: 0%; IR: 0%) were only marginally present. There were no significant differences between males and females or between right- and left-sided pleural fluid in total and differential cell counts. In contrast, in smokers a small but statistically significant increase in pleural fluid neutrophils (median: 1%; IR: 2%; p < 0.015) was observed. In conclusion, PL performed during thoracoscopy for sympathicolysis allowed for the first time determination of the volume and of the total and differential cell contents of the pleural fluid present in normal human pleura.

Needle thoracic sympathectomy for essential hyperhidrosis: intermediate-term follow-up

BACKGROUND

Essential hyperhidrosis is a condition with excessive sweating localized to certain part of the body. A definitive cure can be obtained by upper thoracic sympathectomy.

METHOD

Between June and October 1997, 117 patients with essential hyperhidrosis underwent needle thoracoscopic sympathectomy. Of the 94 patients, 42 were men and 52 women. Their ages ranged from 14 to 63 years, with a mean age of 23 years.

RESULTS

There were no mortality or life-threatening complications. Symptomatic improvement was found in 95.7%. Compensatory hyperhidrosis was found in 71.2% of the patients, but in these compensatory hyperhidrosis were mostly tolerable.

CONCLUSIONS

This therapeutic procedure is minimally invasive and very effective. Further development of the new device and surgical technique are expected to follow.

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.

Endoscopic thoracic sympathectomy

OBJECT

Thoracic sympathectomy has evolved as a treatment option for patients with hyperhidrosis and pain disorders. In the past, surgical procedures were highly invasive and caused significant morbidity, but the minimally invasive thoracoscopic procedure provides detailed visualization of the sympathetic ganglia and is associated with minimal postoperative morbidity.

METHODS

The authors performed 112 thoracoscopic sympathectomy procedures in 65 patients, and the outcomes were equivalent to those previously established for open surgical techniques; however, the rate of surgery-related morbidity, length of hospital stay, and time until return to normal activity were substantially reduced. Complications and recurrence of symptoms were comparable with those demonstrated in previous reports. Overall patient satisfaction and willingness to undergo a repeated operative procedure ranged from 66 to 99%. Postoperatively, higher satisfaction rates were observed in patients with hyperhidrosis whereas in those with pain syndromes, satisfaction rates were lower.

CONCLUSIONS

Minimally invasive thoracoscopic sympathectomy procedures are useful in treating sympathetically mediated disorders, and the results indicate that the procedure is associated with reduced morbidity and similar outcome when compared with results obtained after open surgery. Hyperhidrosis is well treated, but patients with pain syndromes have significantly poorer outcomes.

Thoracoscopic T2-T3 sympathicolysis for essential hyperhidrosis in childhood: effects on pulmonary function

Thoracoscopic T2-T3 sympathicolysis (TS) is a minimally invasive treatment for patients suffering from severe, refractory essential hyperhidrosis (EH). TS has previously been shown to be safe and efficacious in children. In order to examine the effects of TS on respiratory function, pulmonary function tests (PFT) were performed prior to and 6 weeks and 6 months after TS in 12 children with EH (3 boys; mean age 12.8+/-2.5 years). Small asymptomatic decreases in forced expiratory volume in one second (FEV1; -2%), forced expiratory flow after expiration of 75% of vital capacity (FEF75; -9.6%), total lung capacity (TLC; -1%), transfer factor for diffusion of carbon monoxide (T(LCO); -7.6%), and transfer coefficient for diffusion of carbon monoxide (K(CO); -1.5%) were observed 6 weeks after TS. These changes are comparable to those observed in adults but did not reach statistical significance in small children. In line with observations in adults, TLC (and T(L,CO)) returned to baseline values 6 months after TS, whereas FEV1, FEF75, and K(CO) remained at their 6-week level. In conclusion, TS causes only small, statistically insignificant, and asymptomatic decreases in pulmonary function in children. TS can, therefore, be considered a safe treatment option in children suffering from severe, refractory EH.

Therapeutic thoracoscopy

Thoracoscopy provides a minimally invasive window to the pleural space, lung, and mediastinum. Further advances prompted by improvements of specifically designed endoscopic instruments and procedural techniques are expected. There is no doubt that thoracoscopy has a place among therapeutic procedures in the chest. The time-proven principles of thoracic surgical intervention, particularly in regard to patients with cancer, however, must not be neglected. A beckoning window always offers new opportunities, but the open door of classic surgical techniques should not be ignored.

Thoracoscopic splanchnicolysis for the relief of chronic pancreatitis pain: experience of a group of pneumologists

Intractable pain is the most invalidating symptom in patients suffering from chronic pancreatitis. Anatomical interruption of the major afferent pain nerves is indicated in severe refractory cases. Among the various techniques and sites of interruption, thoracoscopic splanchnicectomy has emerged as an efficient alternative for the more aggressive open surgical splanchnicectomy, and for the (solely temporarily efficacious) transcutaneous neural blocks, which moreover bear some serious complications. Until now, all reports on thoracoscopic splanchnicectomy were typically surgical, using video-assisted thoracoscopic surgery techniques, double-lumen intubation, and so on. In analogy with thoracoscopic upper dorsal T2-T3 sympathicolysis for essential hyperhidrosis, a simplified thoracoscopic splanchnicolysis technique used in 8 patients suffering from either severe refractory chronic pancreatitis pain (7 patients) or postsurgical epigastric pain is described. Pain control was achieved in 5 of the 7 patients with chronic pancreatitis with a short (20+/-8 min) intervention, short hospitalization (2 days), and simple (single-lumen intubation, no chest drains) procedure. Thus, this simplified thoracoscopic splanchnicolysis technique may represent a valid alternative in the often difficult treatment of refractory chronic pancreatitis pain or other upper abdominal pain.

Partial pulmonary sympathetic denervation by thoracoscopic D2-D3 sympathicolysis for essential hyperhidrosis: effect on the pulmonary diffusion capacity

In patients with essential hyperhidrosis (EH), a pathological condition characterized by increased activity of the upper dorsal sympathetic ganglia D2-D3, anatomical interruption at the D2-D3 level by thoracoscopic sympathicolysis (TS) is a safe and effective treatment. The D2 and D3 ganglia, however, are also in the pathway of sympathetic lung innervation, which may influence the pulmonary diffusion capacity for carbon monoxide (expressed as transfer factor for CO:TLCO, and as transfer coefficient for CO:KCO). We therefore studied the effect of TS on TLCO and KCO in 50 EH patients: compared with pre-operative values, both TLCO (-6.7%, P < 0.001) and KCO (-4.2%, P = 0.002) were significantly decreased at 6 weeks after bilateral TS, an effect which was independent of the smoking status of the patients. In order to explain this phenomenon, the following pharmacological interventions were studied: (1) oral beta 1 + 2-adrenoreceptor blockade with propranolol caused a comparable decrease of TLCO (-6.3%) and KCO (-7.5%) in matched normal subjects, but had no effect on TLCO and KCO in EH patients prior to TS; and (2) subsequent inhalation of the beta 2-adrenoreceptor agonist salbutamol in a dosage suspected to cause alveolar beta-receptor stimulation had no effect on TLCO and KCO, neither in the normal subjects, nor in EH patients (before and after TS). Although the exact mechanism of the TS-induced decrease in TLCO and KCO remains speculative, these findings suggest that they may be related to a beta 1-adrenoreceptor-mediated change in pulmonary capillary membrane permeability, although TS-induced changes in pulmonary blood flow or an interplay of both mechanisms cannot be excluded.

Essential hyperhidrosis in Turner syndrome

We describe two Turner patients suffering from severe essential hyperhidrosis. Since both disorders are rare (1 in 5000 live female births for Turner syndrome and approximately 1 in 1000 persons for essential hyperhidrosis), our finding of two patients with these disorders in a total of 150 essential hyperhidrosis patients may suggest that this association is more frequent in Turner syndrome than previously thought.