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

Effects of clipping endoscopic thoracal sympathectomy at Th4 on cardiopulmonary functions, quality of life and psychosocial functions

BACKGROUND

In this study, we evaluated the cardiopulmonary and psychosocial effects of endoscopic thoracal sympathectomy (ETS) by clipping procedure at the level of Th₄ and effects of ETS on quality of life of patients with hyperhidrosis.

METHODS

We performed a prospective study in 52 patients complaining of local sweating who applied to our clinic. Cardiac maximal treadmill stress test (CMTST), pulmonary function tests, Beck anxiety-depression inventory, Liebowitz social anxiety scale and SF-36 quality of life questionnaires were administered at preoperative period and postoperative 6th month.

RESULTS

In the pulmonary function test, we found a minimal decrease in FEV1, and FEV1/FVC. There were no significant change in 'resting pulse rate', 'resting systolic and diastolic blood pressures' during CMTST between before and after operation. There was a significant difference in peak heart rate before CMTST, post-exercise diastolic blood pressure, and age-predictive maximal heart rate between before and after clipping procedure. In the SF-36 questionnaire, all parameters were improved. In the Beck depression-anxiety inventory and the Liebowitz social anxiety scale significant improvement was achieved in all parameters.

CONCLUSION

ETS by clipping procedure at the Th₄ level is advised to be a safe and effective method for management of hyperhidrosis patients.

Influence of thoracoscopic sympathectomy on tendency to cry - case-controlled study

Introduction

Primary hyperhidrosis (PHH) is a disease that is mainly characterized by increased palmar and plantar sweating that significantly affects the everyday functioning. It is not clear to what extent this surgical intervention has an effect on one's further emotional functioning.

Aim

To evaluate the impact of endoscopic thoracic sympathectomy (ETS) on crying tendency in PHH patients.

Material and methods

Eighty-six patients qualified for ETS due to PHH took part in the study. All patients completed the Adult Crying Inventory (ACI) and the Functional Assessment of Chronic Illness Therapy (FACIT) questionnaires before and 3 months after sympathectomy. The ACI questionnaire was additionally completed by a group of 60 volunteers.

Results

In females, the number of crying episodes increased after ETS, though it was still lower than the number observed in the control group (1.19 vs. 2.36 vs. 3.83; p < 0.05). In males the number of crying episodes dropped insignificantly to the number observed in the control group (0.87 vs. 0.27 vs. 0.14; p = NS). The tendency to cry in females decreased compared to the level prior to surgery, but it was lower than the level observed in the control group (respectively, 4.5 vs. 3.5 vs. 5.63; p < 0.05). In males the differences were not statistically significant (1.03 vs. 1.5 vs. 1.77; p = NS). There was no impact of emotional status on crying, either before or after the treatment.

Conclusions

Endoscopic thoracic sympathectomy decreases the subjective tendency to cry though it increases the number of crying episodes in women, but does not change crying behaviours in men.

Morphometric study of the upper thoracic sympathetic Ganglia

OBJECTIVE

Morphometric data for the sympathetic ganglia (SG) of the upper thoracic spine was investigated to identify the exact location of the SG in order to reduce normal tissue injury in the thoracic cavity during thoracoscopic sympathectomy.

METHODS

In 46 specimens from 23 formalin-fixed adult cadavers, the authors measured the shortest distance from the medial margin of the T1, T2 and T3 SG to the most prominent point and medial margin of the corresponding rib heads, and to the lateral margin of the longus colli muscle. In addition, the distance between the most prominent point of the rib head and the lateral margin of longus colli muscle and the width of each SG were measured.

RESULTS

The shortest distance from the medial margin of the SG to the prominent point of corresponding rib head was on average 1.9 mm on T1, 4.2 mm, and 4.1 mm on T2, T3. The distance from the medial margin of the SG to the medial margin of the corresponding rib head was 4.2 mm on T1, 5.9 mm, and 6.3 mm on T2, T3. The mean distance from the medial margin of the SG to the lateral margin of the longus colli muscle was 6.7 mm on T1, 8.8 mm, 9.9 and mm on T2, T3. The mean distance between the prominent point of the rib head and the lateral margin of the longus colli muscle was 4.8 mm on T1, 4.6 mm, and 5.9 mm on T2, T3. The mean width of SG was 6.1 mm on T1, 4.1 mm, and 3.1 mm on T2, T3.

CONCLUSION

We present morphometric data to assist in surgical planning and the localization of the upper thoracic SG during thoracoscopic sympathectomy.

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.

Thorascopic sympathectomy performed using laser

INTRODUCTION

Thorascopic sympathectomy is accepted as an effective treatment for palmar hyperhidrosis, facial blushing and to a lesser extent for digital ischaemia and axillary hyperhidrosis.

PATIENTS AND METHODS

Data were collected retrospectively on patients undergoing thorascopic sympathectomy at St Peter's Hospital between 1987 and 2006. Patients were followed up by telephone interview.

RESULTS

A total of 233 thorascopic sympathectomy procedures were performed by a single operator in 123 patients. Ages ranged from 9-71 years and 75 were women. In patients, 105 had a bilateral and 13 a unilateral procedure, 5 patients had a bilateral procedure performed in two stages. In 6 upper limbs, the procedure could not be done. Overall, 110 patients (90%) had the procedure performed for palmar hyperhidrosis, 8 (6%) for facial blushing and in 5 (4%) patients the operation was performed for digital ischaemia with tissue loss. There were no deaths and all patients were discharged on day 1 following the procedure. Complications included bleeding (2), pulmonary oedema (1) and failed procedure (2); however, no incidences of Horner's syndrome occurred. Only 40 of 123 (32.5%) patients gave follow-up information. Of this small group, 33 of 40 (83%) were cured, 4 of 40 (10%) were better, 2 of 40 (5%) were unchanged and 1 patient was worse. Only 22 out of 40 (55%) of these patients were troubled by compensatory sweating, with only 4 of 40 (10%) reporting this as a major problem.

CONCLUSIONS

Thorascopic sympathectomy is safe and can be carried out as a single bilateral procedure in the majority of cases. The laser allows the use of a single port, requires less dissection than surgical or clipping techniques, is more precise than diathermy and may be less likely to cause a Horner's syndrome.

Comparative anatomy of the porcine and human thoracic spines with reference to thoracoscopic surgical techniques

BACKGROUND

This study compared porcine and human thoracic spine anatomies for a better understanding of how structures encountered during thoracoscopy differ between training with a porcine model and actual surgery in humans.

METHODS

Parameters were measured including vertebral body height, width, and depth; disc height; rib spacing; spinal canal depth and width; and pedicle height and width.

RESULTS

Although most porcine vertebral structures were smaller, porcine pedicle height was significantly greater than that of humans because the porcine pedicle houses a unique transverse foramen. The longus colli and psoas attach, respectively, to T5 and T13 in swine and to T3 and T12 in humans. In swine, the azygos vein generally was absent. The intercostal veins drained into the hemiazygos vein.

CONCLUSIONS

Several thoracoscopically relevant anatomic differences between human and porcine spinal anatomies were identified. A thoracoscopic approach in a porcine model probably is best performed from the right side. The best general working area is between T6 and T10.

Severe hyperhidrosis: clinical features and current thoracoscopic surgical management

BACKGROUND

Severe hyperhidrosis is a debilitating disorder primarily affecting the palmar, plantar, and axillary regions. The purpose of our study was to review patient characteristics, surgical technique, and outcome of patients undergoing outpatient thoracoscopic sympathectomy for severe hyperhidrosis.

METHODS

A series of 309 hyperhidrosis patients underwent thoracoscopy for T2-T3 sympathectomy. Of these, 180 underwent prospective evaluation to more precisely identify pre- and postoperative features.

RESULTS

The primary indication for surgery was palmar hyperhidrosis (PH) in 302 of 309 patients (97.7%), although in 7 patients (2.3%) axillary hyperhidrosis (AH) was the primary indication. A family history was elicited in 74 of 132 (56.1%) and a provocative response to hand lotion was present in 101 of 132 (76.5%). Thoracoscopic sympathectomy afforded almost instantaneous cures for PH, with marked improvement in 100% for whom the sympathectomy was done. Of 180 patients prospectively questioned in detail, 173 (96.1%) had some degree of plantar hyperhidrosis. Of these, 148 (84.4%) had some improvement, with 70 (40.5%) achieving complete relief of the plantar hyperhidrosis. In 98 patients who had some complaints of AH, 68 (69.4%) were completely relieved of the AH, while 25 (25.5%) were relieved but not completely cured. In 7 patients, the primary indication for sympathectomy was AH and of these, 3 (42.9%) had complete relief, 2 (28.6%) had partial relief, and 2 (28.6%) had no relief. Of the entire series of 309 patients, 4 (1.3%) developed severe compensatory hyperhidrosis (CH). In 180 prospectively questioned patients, CH was present in 81 (45%).

CONCLUSIONS

The most frequent presentation of hyperhidrosis involves the hands and feet. A family history of the disorder is common, and there is usually a provocative effect with hand lotion. Sympathectomy at the level of the T2-T3 ganglia is curative for PH, and in 80% of instances will improve plantar hyperhidrosis when in combination with PH. Sympathectomy for AH is not as effective as for PH. CH is common, occurring in nearly half, but only rarely is extreme and problematic. Bilateral thoracoscopic sympathectomy may be safely done as an outpatient procedure for most patients.