Microinvasive transaxillary thoracoscopic sympathectomy: technical note

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.

Laser Doppler scanning study of palmar skin perfusion for patients with hyperhidrosis before and after thoracic sympathectomy

BACKGROUND

Palmar hyperhidrosis is effectively treated by thoracic sympathectomy. Previous reports revealed that palmar skin temperature and perfusion increased on focal palmar regions after treatment. This study aimed to investigate the blood flow change over the whole palmar surface after the procedure.

METHODS

Thirty patients with severe palmar hyperhidrosis were included for study. Each participant received measurement of palmar skin perfusion by a laser Doppler image scanner 1 day before and 1 day after surgery. Concomitantly, palmar skin temperature was recorded by a contact thermometer probe. One patient underwent intraoperative recording of palmar skin perfusion.

RESULTS

Palmar skin perfusion and temperature increased significantly after thoracic sympathectomy. Intraoperative measurement performed for a patient showed a similar trend of increment of palmar skin blood flow.

CONCLUSIONS

The global skin perfusion of palms can be analyzed in real time by the laser Doppler image scanner. This technique could be useful for analysis of blood flow changes in other body surface regions after thoracic sympathectomy.

History of neuroendoscopy

Since the beginnings of medicine, physicians have sought minimally invasive ways to peer into body cavities. It is only in the last several decades that the promises of endoscopy have begun to be answered. What follows is a brief outline of the development of endoscopic technology and its application to the nervous system both for diagnostic and therapeutic procedures.

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.

Video-assisted thoracoscopic sympathectomy for congenital long QT syndromes

The feasibility, safety, and effectiveness of video-assisted thoracoscopic sympathectomy (VATS) for congenital long QT syndrome were assessed in four patients who had frequent syncopal events before the surgeries. Under general anaesthesia, the pleural cavity was entered via two small incisions in the left third and fifth intercostal spaces at the mid-axillary line. The left thoracic sympathetic chain was identified and resected from T2-T5. The lower one third of the left stellate ganglion was also resected. VATS resulted in a significant shortening in corrected QT intervals (QTc) in three patients, the average QTc of the four patients immediately before and after VATS was 538 +/- 76 and 512 +/- 57 ms, respectively (P = 0.047). The heart rate remained unchanged after the VATS (67 +/- 4 vs 69 +/- 4 beats/min, P > 0.05). There were no major perioperative complications apart from mild ptosis of the left upper eyelid in one patient who recovered in the following days. There was no recurrence in syncopal events after a 3-month follow-up. VATS is a safe and effective technique for left cardiac sympathectomy in patients with congenital long QT syndromes.

Sympathotomy instead of sympathectomy for palmar hyperhidrosis: minimizing postoperative compensatory hyperhidrosis

OBJECTIVE

To determine whether anatomical modification of sympathectomy diminishes severe postoperative compensatory hyperhidrosis.

PATIENTS AND METHODS

From January 1, 2000, to June 1, 2001, we prospectively studied 10 consecutive patients with primary palmar hyperhidrosis, aged 14 to 42 years. Medical therapy had failed in all patients. A preoperative and postoperative evaluation and thermoregulatory sweat testing were conducted in all patients. All patients underwent sympathotomy (bilateral simple disconnection) of the second thoracic ganglion input into the brachial plexus, and no sympathetic ganglia were violated.

RESULTS

In the 10 patients, all 20 upper extremities improved postoperatively: 11 (55%) had near-complete cessation of palmar sweating, 8 (40%) had marked reduction in sweating, and 1 (5%) had delayed onset but full sweating at the end of the thermoregulatory sweat test. No intraoperative complications of hemopneumothorax or Horner syndrome occurred. Importantly, there were no moderate or severe postoperative hyperhidrosis complications.

CONCLUSION

Sympathotomy to disconnect T2 ganglion input into the brachial plexus produces excellent results in the treatment of primary palmar hyperhidrosis and may lower the severity of postoperative compensatory hyperhidrosis complications. Long-term durability of the procedure requires further follow-up.