Uniportal endoscopic superior thoracic sympathectomy

Optimal targeting of sympathetic chain levels for treatment of palmar hyperhidrosis: an updated systematic review

BACKGROUND

Palmar hyperhidrosis involves excessive sweating of the palms, with no known etiology. Endoscopic thoracic sympathectomy (ETS) is a safe and effective treatment for palmar hyperhidrosis, but compensatory hyperhidrosis is a common complication after ETS, leading to reduced patient satisfaction and postoperative quality of life. However, the appropriate level of the sympathetic chain to target with ETS to achieve maximum efficacy and reduce the risk of compensatory hyperhidrosis (CH) is controversial. In this systemic review, we investigated the appropriate level of sympathectomy for palmar hyperhidrosis.

METHODS

PRISMA guidelines were implemented to complete a systematic review. We performed a computerized systematic literature search using PubMed and EMBASE from January 1990 to July 2016. We chose the Cochrane Collaboration's tool and the methodological index for non-randomized studies tool for examining study bias.

RESULTS

A total of 4075 citations were identified, of which 91 were eligible for inclusion, including 68 observational studies and 23 comparative trials. In observational studies, sympathectomies showed similar efficacies for curing PH at different levels. However, T2-free groups (i.e., at levels T3, T4, or T3-T4 combined) could render a lower risk of Horner's syndrome (0 vs. 1.21 ± 0.49%, p = 0.036) and CH (28.75 ± 7.25 vs. 57.46 ± 3.86, p = 0.002) compared with T2 involved. In comparative trials, there were 12 studies describing the comparison between T2-free ETS and T2 involved, and 9 of 12 (75%) showed T2-free ETS could reduce the incidence of CH. Overall, lowering the level and limiting the extent of sympathectomy could reduce the incidence of complications.

CONCLUSIONS

Cumulative data from more than 13,000 patients suggest that ETS is a safe, effective, and reproducible procedure with a high degree of patient satisfaction. Currently available evidence suggests that T2-free ETS may reduce the incidence of compensatory hyperhidrosis without compromising success rates and safety.

Endoscopic transthoracic limited sympathotomy for palmar-plantar hyperhidrosis: outcomes and complications during a 10-year period

OBJECTIVE

To review surgical results of endoscopic transthoracic limited sympathotomy for palmar-plantar hyperhidrosis during the past decade.

PATIENTS AND METHODS

We retrospectively reviewed 155 consecutive patients who underwent surgery from June 30, 2000, through December 31, 2009, for medically refractory palmar-plantar hyperhidrosis using a technique of T1-T2 sympathotomy disconnection, designed for successful palmar response and minimization of complications.

RESULTS

Of the 155 patients, 44 (28.4%) were male, and 111 (71.6%) were female; operative times averaged 38 minutes. No patient experienced Horner syndrome, intercostal neuralgia, or pneumothorax. The only surgical complication was hemothorax in 2 patients (1.3%); in 1 patient, it occurred immediately postoperatively and in the other patient, 10 days postoperatively; treatment in both patients was successful. All 155 patients had successful (warm and dry) palmar responses at discharge. Long-term follow-up (>3 months; mean, 40.2 months) was obtained for 148 patients (95.5%) with the following responses to surgery: 96.6% of patients experienced successful control of palmar sweating; 69.2% of patients experienced decreased axillary sweating; and 39.8% of patients experienced decreased plantar sweating. At follow-up, 5 patients had palmar sweating (3 patients, <3 months; 1 patient, 10-12 months; 1 patient, 16-18 months). Compensatory hyperhidrosis did not occur in 47 patients (31.7%); it was mild in 92 patients (62.2%), moderate in 7 patients (4.7%), and severe in 2 patients (1.3%).

CONCLUSION

In this series, a small-diameter uniportal approach has eliminated intercostal neuralgia. Selecting a T1-T2 sympathotomy yields an excellent palmar response, with a very low severe compensatory hyperhidrosis complication rate. The low failure rate was noted during 18 months of follow-up and suggests that longer follow-up is necessary in these patients.

Endoscopic thoracic sympathectomy for primary palmar hyperidrosis

BACKGROUND

Primary hyperhidrosis is a disorder that is characterized by excessive sweating in disproportion to that required for thermoregulation. In most cases, this is aggravated by emotional factors and by heat. Hyperhidrosis can be seen in the palms of the hands, armpits, soles of the feet and face. The principal characteristic of this disease is the intense discomfort of patients, which affects their social and professional life. Treatment modalities include topical application of aluminum chloride, iontophoresis, anticholinergics, botulinum toxin injection, liposuction, excision of sweat glands, and thoracic sympathectomy.

METHODS

Between January 1998 and August 2007, a prospective study of endoscopic thoracic sympathectomies for palmar hyperhidrosis was undertaken based on case histories and a prospective pre- and postoperative questionnaire survey. The sample comprised of 322 patients with a mean age of 24 years. At Apollo Hospital, New Delhi, India, bilateral video-assisted thoracoscopic T3 level sympathectomies were performed in all cases.

RESULTS

All patients had immediate cessation of palmar hyperhidrosis. The mean postoperative stay was 1.1 days. A questionnaire was completed based on their response to a telephone conversation or e-mail. A paired t test and Wilcoxon test was performed on these data and it showed significant improvement in quality of life. Compensatory sweating was found to be the most troublesome side effect for all patients. It was seen in 63% of the patients. This is similar to other reports of compensatory sweating; however, the figure decreases to 29% if we disregard the percentage of patients who reported only mild compensatory sweating.

CONCLUSION

In view of the low morbidity and zero mortality rate of this surgical technique, we recommend it as a method of treatment for palmar hyperhidrosis. Thoracic sympathectomy eliminates palmar hyperhidrosis with minimal recurrence (1% in our series) and produces a high rate of patient satisfaction.

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.

A comprehensive approach to the recognition, diagnosis, and severity-based treatment of focal hyperhidrosis: recommendations of the Canadian Hyperhidrosis Advisory Committee

BACKGROUND

Hyperhidrosis can have profound effects on a patient's quality of life. Current treatment guidelines ignore disease severity.

OBJECTIVE

The objective was to establish clinical guidelines for the recognition, diagnosis, and treatment of primary focal hyperhidrosis.

METHODS AND MATERIALS

A working group of eight nationally recognized experts was convened to develop the consensus statement using an evidence-based approach.

RECOMMENDATIONS

An algorithm was designed to consider both disease severity and location. The Hyperhidrosis Disease Severity Scale (HDSS) provides a qualitative measure that allows tailoring of treatment. Mild axillary, palmar, and plantar hyperhidrosis (HDSS score of 2) should initially be treated with topical aluminum chloride (AC). If the patient fails to respond to AC therapy, botulinum toxin A (BTX-A; axillae, palms, soles) and iontophoresis (palms, soles) should be the second-line therapy. In severe cases of axillary, palmar, and plantar hyperhidrosis (HDSS score of 3 or 4), both BTX-A and topical AC are first-line therapy. Iontophoresis is also first-line therapy for palmar and plantar hyperhidrosis. Craniofacial hyperhidrosis should be treated with oral medications, BTX-A, or topical AC as first-line therapy. Local surgery (axillary) and endoscopic thoracic sympathectomy (palms and soles) should only be considered after failure of all other treatment options.

CONCLUSIONS

These guidelines offer a rapid method to assess disease severity and to treat primary focal hyperhidrosis according to severity.

Thoracoscopic sympathectomy for palmaris hyperhidrosis

INTRODUCTION

Palmaris hyperhidrosis is a disorder mediated by the sympathetic nervous system. It causes excessive sweating. This study evaluated the safety, efficacy, and outcome after thoracoscopic sympathectomy in patients with palmaris hyperhidrosis.

METHODS

We reviewed the medical records of 18 patients (10 male) who underwent bilateral thoracoscopic sympathectomy between July 1998 and June 2001.

RESULTS

The patients' mean age was 34 years. No conversions to thoracotomy occurred. Three 2- to 5 mm trocars were used. The thoracic sympathetic chain was resected from ganglia T2-T4, except in one patient with axillary hyperhidrosis requiring resection to T5. The mean operating time was 112 minutes, the mean blood loss was 50 ml, and the mean postoperative hospital stay was 1.2 days. Two patients had a unilateral pneumothorax requiring tube thoracostomy; one patient developed a chest wall hematoma at a trocar site that resolved without treatment, and one patient developed a transient unilateral Horner's syndrome. There have been no hospital readmissions. After a mean follow-up period of 14 months, 11 patients (56%) reported compensatory sweating. Sixteen patients (89%) were satisfied with their outcomes. One patient was dissatisfied because of excessive compensatory sweating, and another continues to have mild unilateral sweating on one hand and compensatory sweating of the face.

CONCLUSION

Thoracoscopic sympathectomy is a safe and effective alternative treatment for palmaris hyperhidrosis. Compensatory sweating occurs in more than 50% of patients but is tolerable in most. The majority of patients are satisfied with their short-term outcomes.