Video-assisted Transthoracic Sympathectomy in the Treatment of Primary Hyperhidrosis: Friend or Foe?:

Anatomical variations of the thoracic sympathetic ganglions and their effects on sympathicotomy for primary palmar hyperhidrosis

PURPOSE

The results and side effects of sympathicotomy for primary palmar hyperhidrosis (PPH) can vary due to anatomical variations of the sympathetic ganglions. The aim of our study was to clarify anatomical variations of the sympathetic ganglions by near-infrared (NIR) thoracoscopy and determine their effects on sympathicotomy for PPH.

METHODS

The cases of 695 consecutive patients with PPH treated with either R3 or R4 sympathicotomy either by normal thoracoscopy or by NIR fluorescent thoracoscopy between March 2015 and June 2021 were retrospectively reviewed and followed up.

RESULTS

The variation rate of third and fourth ganglions was 14.7% and 13.3% on the right side and 8.3% and 11.1% on the left side. Real T3 sympathicotomy (RTS₃) was more effective than real T4 sympathicotomy (RTS₄) in the short-term and long-term follow-up (p < 0.001 and p < 0.001, respectively). RTS₃ was more satisfactory than RTS₄ in the long-term follow-up (p = 0.03), but no significant difference was found in the short-term follow-up (p = 0.24). The incidence and severity of compensatory hyperhidrosis (CH) in the areas of the chest and back in the RTS₄ group were significantly lower than those in the RTS₃ group according to both the short-term results (12.92% vs. 26.19%, p < 0.001; 17.97% vs. 33.33%, p = 0.002, respectively) and the long-term results (19.66% vs. 28.57%, p = 0.017; 21.35% vs. 34.52%, p < 0.001, respectively).

CONCLUSIONS

RTS₃ may be more effective than RTS₄ for PPH. However, RTS₄ appears to be associated with a lower incidence and severity of CH in the areas of the chest and back than RTS_3. NIR intraoperative imaging of thoracic sympathetic ganglions may improve the quality of sympathicotomy surgeries.

A prospective controlled randomized multicenter study to evaluate the severity of compensatory sweating after one-stage bilateral thoracic sympathectomy versus unilateral thoracic sympathectomy in the dominant side

OBJECTIVE

To evaluate the contribution that unilateral thoracic sympathectomy in dominant side or two-stage bilateral thoracic sympathectomy can have as strategies to reduce the incidence of compensatory sweating after sympathectomy for palmar hyperhidrosis.

METHODS

This is a prospective, controlled, randomized multicenter trial of 200 participants with palmar hyperhidrosis, which will be randomized into two arms: (a) one-stage bilateral thoracic sympathectomy (control arm); or (b) unilateral thoracic sympathectomy in dominant side (intervention arm). At six months the participants submitted to unilateral procedure can make the contralateral surgery if they wanted it, creating a third group called two-stage bilateral sympathectomy. Participants will be evaluated for the degree of sweating by the Hyperhidrosis Disease Severity Scale (HDSS) and of quality of life questionnaires.

RESULTS

96 participants out of the 200 proposed have been included so far, with 48 participants randomized to each arm. From the sample 61 (63.5%) are female, with a mean age of 24 (20-32) years. There were exclusive palmar hiperhydrosis in 14 cases (14.5%), palmar and plantar hyperhidrosis in 36 (37.5%) cases, palmar and axillar hyperhidrosis in 12 (12,5%) cases and palmar-axillary-plantar hyperhidrosis in 34 (35,4%) cases. The age at the beginning of the disease was childhood (78%), with mean of time of disease 15 (11-22) years.

CONCLUSIONS

If one or both hypothesis: (a) unilateral sympathectomy in dominant hand is a satisfactory treatment; b) two-stage bilateral sympathectomy causes less compensatory sweating than in one stage are confirmed there is a chance that surgical therapy for palmar hyperhidrosis can be changed for better.

Bilateral R5-R8 sympathectomy for compensatory hyperhidrosis: complications and patient satisfaction

OBJECTIVE

The purpose of this study was to assess the quality of life of patients who had undergone bilateral thoracic sympathectomy from R5 to R8 as a treatment for severe and debilitating compensatory hyperhidrosis (CH).

METHODS

Twelve patients with severe and debilitating compensatory hyperhidrosis underwent extended sympathectomy (R5-R8) from September 2016 to May 2019 at the Hospital das Clínicas, Federal University of Pernambuco, Brazil. Outcomes such as the level of patient satisfaction with the operation, quality of life scores as well as postoperative complications were assessed.

RESULTS

There has been a substantial improvement in the quality of life score of 66% of the sample. In all four domains, a statistical significant difference was seen, regarding the relief of compensatory hyperhidrosis symptoms.

CONCLUSIONS

Extended sympathectomy from R5 to R8 was shown to be quite effective in most cases, leading us to believe that this approach could be a therapeutic option for severe compensatory hyperhidrosis.

Quality of Life Changes Following Surgery for Hyperhidrosis

The best way to evaluate the impact of primary hyperhidrosis on quality of life (QL) is through specific questionnaires, avoiding generic models that do not appropriately evaluate individuals. QL improves significantly in the short term after sympathectomy. In the longer term, a sustained and stable improvement is seen, although there is a small decline in the numbers; after 5 and even at 10 years of follow-up it shows virtually the same numerical distribution. Compensatory hyperhidrosis is a major side effect and the main aggravating factor in postoperative QL, requiring attention to its management and prevention.

One-port videothoracoscopic surgical intervention

BACKGROUND

One-port video-assisted thoracic surgery (VATS) has recently been proposed as an alternative to conventional 3-port VATS. To reduce pain, chest wall paresthesia, and hospital stay, lesser ports are the current direction.

MATERIALS AND METHODS

From 2007 to 2010, 98 patients underwent 1-port VATS procedure. The charts were retrospectively evaluated. A 2.5 cm long incision was made at the sixth intercostal space in the median axillary line. A single flexible port was used. Both the camera and the endoinstruments were introduced through the port. Patient characteristics, visual analog score, and postoperative paresthesia scores were evaluated.

RESULTS

The study enrolled 38 women and 60 men with the mean age of 49.1±1.5 years (range, 19 to 75 y). Thirty-one patients (28.6%) were diagnosed with malignant pleural effusion. Perioperative pleurodesis with talc was performed in 81% of them. One-port VATS approach was used for pleura biopsies in 77 (78.6%), wedge resection in 4 (3.8%), pleurectomy in 13 (12.4%), and biopsy with talc chemical pleurodesis in 4 (3.8%) instances. The mean operation time was 24.4 minutes (range, 15 to 50 min). No major cardiorespiratory or surgical complications were noted. The median observation time was 60 months (range, 36±81 mo). Among benign pathology patients, 56 (82.3%) of them did not complain about any pain; however, 12 patients had prolonged discomfort (2 pinprick, 6 numbness, and 4 pruritus).

CONCLUSIONS

One-port VATS in selected patients are feasible and seems to be safe in thoracic surgical interventions instead of conventional 3 ports that was presented in this series.

Evidence-based consensus development and reduction of rate of endoscopic thoracic sympathectomy: a national study

BACKGROUND

Endoscopic thoracic sympathectomy (ETS) was overused for treating patients with hyperhidrosis in Taiwan.

OBJECTIVES

To determine whether use of evidence and a consensus-building exercise can reduce rates of surgery.

METHODS

We invited all surgeons in Taiwan who performed five or more ETSs per year for treating patients with hyperhidrosis to join this study. A structured questionnaire was mailed to surgeons asking about their management decisions based on clinical scenarios. Then we provided surgeons with evidence synopses and used the Delphi method to reach consensus. We analyzed healthcare utilization data during 2000 to 2005 and calculated total numbers of ETSs performed per 12 months to examine the effect on surgeons' behavior.

RESULTS

Of 155 surgeons invited, 61 (40%) completed this study. They agreed that observation or topical therapy was appropriate for patients with mild palmar hyperhidrosis, whereas ETS was appropriate for children, adolescents, and young and middle-aged adults who had severe symptoms. Surgeons became more willing to recommend botulinum toxin injection after we provided evidence synopses. We found a 52% reduction in mean total ETSs per 12 months in surgeons receiving evidence synopses. A higher percentage of reduction occurred in patients younger than 12 and aged 60 and older.

CONCLUSION

Evidence-based consensus development is helpful in decreasing overuse of ETS in treating patients with hyperhidrosis in Taiwan.

Botulinum toxin: a treatment for compensatory hyperhidrosis in the trunk

BACKGROUND

Severe compensatory hyperhidrosis (CH) in the trunk occurs after sympathectomy in some patients. Limited treatment options for these cases have been proposed, and the overall results have been disappointing, but injection of botulinum toxin-A (BTX-A) is an emerging, reliable treatment method for focal hyperhidrosis.

OBJECTIVE

To demonstrate the efficacy, longevity, and safety of BTX-A injection for severe truncal sweating in CH patients who were refractory to conventional treatment.

METHODS

Seventeen patients were injected with 100 to 500 U of BTX-A in the truncal area. After the follow-up period, the Hyperhidrosis Disease Severity Scale (HDSS) for efficacy and the Dermatology Life Quality Index (DLQI) were measured for improvement in patients' quality of life.

RESULTS

The baseline mean HDSS score+/-standard deviation was 3.6+/-0.5, and the sweating resolved within 5 days. The effect was sustained for 2 to 8 months (4.1+/-1.5 months) and the baseline DLQI score of 9.4+/-2.0 fell to 2.8+/-1.0. No serious side effects or adverse events resulted from the treatment.

CONCLUSIONS

BTX-A injection was a well-tolerated, effective, and safe method for treating severe truncal CH, although the considerable cost and limited duration of the treatment effects were major disadvantages.

Compensatory sweating after thoracoscopic sympathectomy: an acceptable trade-off

BACKGROUND/PURPOSE

Palmar hyperhidrosis is a fairly common condition that is treatable by thoracoscopic sympathectomy (TS). Compensatory sweating (CS) is a major side effect of TS. We surveyed post-TS patients to determine the procedure's long-term success, satisfaction, complications, the natural history of CS, and whether those with CS would still have undergone the procedure.

METHODS

A chart review of all patients who had undergone TS at 2 medical centers yielded 621 patients (mean age, 16.1 years) with a follow-up of more than 24 months: 265 (43%) could be contacted and agreed to reply to a detailed telephone questionnaire.

RESULTS

Most participants (97%) reported complete (89.4%) or reasonable (7.6%) symptomatic relief. The long-term postoperative satisfaction was high (84.5%). Forty-one percent of the participants claimed that their quality of life decreased moderately or severely as a result of CS. Only 19.6% would not have undergone the operation in retrospect; there was a significant interesting difference regarding this issue between adults (31.4%) and children (8.8%). The extent of the CS did not change with time in 70% of the patients. It exacerbated in 10% and it diminished in 20%, usually within the first 2 postoperative years.

CONCLUSIONS

Thoracoscopic sympathectomy relieves hyperhidrosis in most cases. Patients prefer relief from palmar hyperhidrosis even at the cost of a high rate of CS. Hyperhidrosis is not a self-limiting condition, and we recommend not postponing TS until adulthood.

[Thoracic sympathectomy in primary hyperhidrosis: patient satisfaction]

OBJECTIVE

To evaluate satisfaction among patients who underwent thoracic sympathectomy for primary hyperhidrosis and the possible complications after a minimum of 14 months after surgery.

MATERIAL AND METHODS

We performed a retrospective study in 108 patients who underwent thoracic sympathectomy and who responded to all the questions asked in a telephone interview. The sample was composed of 21 men and 87 women, with a mean age of 29.73 years. In all patients, surgery was performed with general anesthesia in a single intervention. Special emphasis was placed on the degree of satisfaction (whether patients would recommend this type of surgery) and the possible negative effects or complications experienced by patients or attributed by them to the procedure.

RESULTS

Patients were contacted a minimum of 14 months after the intervention. The most frequent complication was compensatory sweating (81.5%). Pain at the site of trocar insertion was reported by 6.5%. There were few immediate and long-term complications. The degree of satisfaction reached 90.7%.

CONCLUSION

Video-assisted thoracic sympathectomy is safe and effective. Despite compensatory sweating, overall satisfaction was very high. However, satisfaction gradually decreased in the months after the intervention. Patients with hyperhidrosis with significant or principal axillary involvement could benefit from botulinic toxin administration as the first-line therapy.

One-Year Follow-Up After Thoracoscopic Sympathectomy for Hyperhidrosis: Outcomes and Consequences

BACKGROUND

Thoracic sympathectomy is recognized as an effective treatment for patients with severe hyperhidrosis. While good early results have been documented, continuing efficacy and patient satisfaction has not been well-defined. We reviewed our results in patients who were at least one year out from surgery.

METHODS

All procedures were performed thoracoscopically using bilateral 3 mm ports and excision of a segment of the sympathetic chain by electrocautery. The level of sympathectomy depended upon clinical symptoms: T2 for face/scalp, T3 for palmar hyperhidrosis, and T4 for axillary hyperhidrosis, or a combination of levels for multiarea sweating. All patients were followed-up at least 1 year postprocedure by mail questionnaire and/or telephone.

RESULTS

Two hundred twenty-two patients had undergone thoracoscopic sympathectomy for essential hyperhidrosis between Jan 1, 2002 and Nov 30, 2003, with 170 patients having at least one-year follow-up. The patients' preoperative assessment of the severity of sweating in the affected areas was compared with their one-year evaluation in order to determine the durability of the procedure. All affected areas continued to show significant improvement in sweating as compared with preoperative symptoms. Compensatory sweating was reported in 85% of our patients at one-year follow-up. Patients with a T2 lesion were significantly more likely to have severe compensatory sweating than those with other levels; 48.8% vs 16.1% (p < 0.001). Patients with levels other than T2 reported high degrees of satisfaction unrelated to their postoperative compensatory symptoms.

CONCLUSIONS

Patient satisfaction and perceived effectiveness with sympathectomy for palmar or axillary hyperhidrosis remain high even one year after the procedure. Inclusion of the T2 lesion results in significantly more severe compensatory sweating and reduced satisfaction than other levels.

Gustatory Side Effects After Thoracoscopic Sympathectomy

BACKGROUND

Compensatory sweating is a frequent side effect after thoracoscopic sympathectomy for primary hyperhidrosis. Gustatory sweating is less commonly reported. It is defined as facial sweating when eating certain foods (particularly spicy food or acidic fruits) and has no generally accepted pathophysiologic explanation. We decided to investigate this phenomenon in patients who underwent thoracoscopic sympathectomy for primary hyperhidrosis and analyze whether the occurrence was influenced by the extent of sympathectomy.

METHODS

During an 8-year period (1997 to 2005) a total of 238 patients were treated by thoracoscopic sympathectomy for primary hyperhidrosis or blushing. Sympathectomy was performed bilaterally at T2 for facial hyperhidrosis or blushing (n = 97), T2-T3 for palmar hyperhidrosis (n = 76), and T2-T4 for axillary hyperhidrosis (n = 65). All patients received the same questionnaire at follow-up.

RESULTS

The questionnaire was returned by 96% of patients after a median of 17 months. Overall, gustatory sweating occurred in 32% of patients, and the incidence was significantly associated with extent of sympathectomy (p = 0.04). However, because the extent of sympathectomy was always decided by the location of primary hyperhidrosis, the latter may also explain the risk of gustatory sweating.

CONCLUSIONS

Gustatory sweating is a frequent side effect after thoracoscopic sympathectomy. This is the first study to report that its incidence is significantly related to the extent of sympathectomy or the location of primary hyperhidrosis. Although there is no pathophysiologic explanation of gustatory sweating, these findings should be considered before planning thoracoscopic sympathectomy and patients should be thoroughly informed.

Palmar hyperhidrosis—which is the best level of denervation using video-assisted thoracoscopic sympathectomy: T2 or T3 ganglion?

PURPOSE

This study compares early results of video-assisted thoracoscopic sympathectomy (VTS) at the thoracic T2 versus T3 ganglion denervation levels for the treatment of palmar hyperhidrosis (PH).

METHODS

Sixty patients with PH were prospectively randomized for VTS at the thoracic T2 or T3 ganglion denervation levels. The patients underwent postoperative evaluation on three occasions: before surgery, and 1 and 6 months after the operation. Endpoints included the absence of PH, the presence, location, and severity of compensatory hyperhidrosis (CH), and a quality-of-life assessment.

RESULTS

Fifty-nine of 60 patients reported complete resolution of PH after surgery. One failure occurred in the T3 group. CH was observed in 26 patients (86.66%) in the T2 group and in 27 patients (90%) in the T3 group at 1 month. At 6 months, 30 of 30 patients in the T2 group and 29 of 30 in the T3 group experienced CH, although in the T3 group, CH was less severe at both 1 and 6 months (P < .05). Quality of life was very poor in both groups before surgery. One month after operation, quality of life was improved similarly in both groups. This improvement was maintained at 6 months in both groups.

CONCLUSION

PH is well treated by VTS at either the T2 or T3 levels. Denervation at the T3 level appears associated with less severe CH in the early postoperative period. Quality of life improved significantly in both groups.

Severity of compensatory sweating after thoracoscopic sympathectomy

BACKGROUND

Compensatory sweating is a well-known side effect after sympathectomy for hyperhidrosis. It is often claimed to correlate with the extent of sympathectomy, but results from the literature are conflicting, and few have actually considered differences in the intensity of compensatory sweating.

METHODS

A total of 158 patients underwent thoracoscopic sympathectomy for primary hyperhidrosis or blushing, or both. Sympathectomy was performed bilaterally at Th2 for facial hyperhidrosis/blushing (n = 49), Th2-3 for palmar hyperhidrosis (n = 62), and Th2-4 for axillary hyperhidrosis (n = 47).

RESULTS

Follow-up by questionnaire was possible in 94% of patients after a median of 26 months. Compensatory sweating occurred in 89% of patients and was so severe in 35% that they often had to change their clothes during the day. The frequency of compensatory sweating was not significantly different among the three groups, but severity was significantly higher after Th2-4 sympathectomy for axillary hyperhidrosis (p = 0.04). Gustatory sweating occurred in 38% of patients, and 16% of patients regretted the operation.

CONCLUSIONS

Compensatory and gustatory sweating were remarkably frequent side effects after thoracoscopic sympathectomy for primary hyperhidrosis. We found no significant difference between the level of sympathectomy and the occurrence of compensatory sweating. However, it appears that this is the first study to demonstrate that severe sweating is significantly more frequent after Th2-4 sympathectomy for axillary hyperhidrosis. We encourage informing patients thoroughly about these side effects before surgery.

Long-Term Results of Thoracoscopic Sympathectomy for Hyperhidrosis

BACKGROUND

Thoracoscopic sympathectomy is now the reference treatment for severe palmar hyperhidrosis, but this is offset by the occurrence of compensatory sweating. It has been studied in this series to improve the indications and information given to patients.

METHODS

A retrospective review of 124 patients who were previously afflicted with bilateral thoracoscopic sympathectomy 6 years earlier was conducted. Patients were interviewed by postal questionnaire regarding the results and side effects.

RESULTS

The series consisted of 89 females (72%) and 35 males and the mean age was 28 years. The main indication was palmo-plantar hyperhidrosis (34%). The mean operating time was 36 minutes and there were no intraoperative complications. Postoperative pneumothorax occurred in 9 patients and 3 patients required a chest drain. The hospital stay was 36 hours for 87.6% of the patients. Postoperative pain occurred in 78% of the patients. Neurologic complications (Horner syndrome, radial paralysis, and dysesthesia of the arm) occurred in 3 patients and disappeared after 2-6 months. Two patients required single-side reoperation because of failure with the first intervention. Eighty-nine replies to questionnaires were received (72%). The results for hands were favorable in 98% and in 63% for axillae. Compensatory sweating occurred in 87% of the patients (serious in 36% and incapacitating in 6%). Despite this 90% of the patients were satisfied or very satisfied.

CONCLUSIONS

This study confirms that thoracoscopic sympathectomy is a suitable method of treatment for severe palmar hyperhidrosis but emphasizes the need to offer the patient more informative information, especially regarding compensatory sweating which seems inescapable.

Quality of life, before and after thoracic sympathectomy: report on 378 operated patients

BACKGROUND

Thoracic sympathectomy is indicated to treat primary hyperhidrosis. The objective is to analyze the results and complications of thoracic sympathectomy and propose a questionnaire to assess the quality of life of patients.

METHODS

Between October 1995 and March 2002, 378 patients were evaluated. Sixty-two percent were female, with a mean age of 26.8 years old (range 9 to 70 years old). There were 57.4% patients with palmar-plantar hyperhidrosis; 25% with palmar, plantar, and axillary hyperhidrosis; 15.7% with pure axillary hyperhidrosis; and 6.5% with craniofacial hyperhidrosis. General anesthesia was used in 97.3%, epidural with sedation in 2.7%. The sympathetic chain was resected in 12.5%, thermal ablation with the electrical scalpel was performed in 66.3%, and with the harmonic scalpel in 21.2% of the patients.

RESULTS

Successful sympathectomies were performed in 90.3% of the patients; the follow-up was from 1 to 60 months (mean 12.4 +/- 8.3 months). The recurrence rates were 8.2% for palmar hyperhidrosis, 13.7% for pure axillary hyperhidrosis, 27.5% of which were reoperated successfully. Improvement of the plantar hyperhidrosis was also registered in 58%. Horner's syndrome was reported in 1% with regression in half of them after 30 days. No mortality or serious complications were observed, nor the need to convert to thoracotomy. Of the total number of patients, 93.4% answered the quality of life questionnaire, 86.4% of whom noted improvement after the procedure.

CONCLUSIONS

Thoracic sympathectomy is a simple, effective, safe method for the treatment of hyperhidrosis, resulting in an improved quality of life for patients. The questionnaire documents this change.

[Histopathological changes in sympathetic ganglia of patients treated surgically for palmar-axillary hyperhidrosis. A study of 55 biopsies]

INTRODUCTION

Primary palmar hyperhidrosis (PPH) mainly affects the sympathetic ganglia. This study aims to analyze the histopathological changes in the sympathetic ganglia of patients with PPH.

MATERIAL AND METHOD

We studied 55 tissue samples from 35 patients with PPH who underwent T2-T3 gangliectomy for definitive treatment of their disease, analyzing the presence of inflammation, chromatolysis and lipofuscin accumulation. Findings were analyzed in relation to age, compensatory sweating and type of surgery: unilateral, synchronic bilateral or sequential bilateral.

RESULTS

We found inflammation in 5.5%, chromatolysis in 61.8% and lipofuscin accumulation in 41.8% of the samples. Chromatolysis and lipofuscin were found without inflammation in 32.1%. Chromatolysis and lipofuscin accumulation were each found in 60% of the samples from synchronic bilateral sympathectomies. However, those percentages decreased between the first and second sympathectomies in sequential procedures, such that chromatolysis was found in 71.4% of first-procedure samples and 42.8% of second-procedure samples; the rates for lipofuscin accumulation changed from 64.2% to 14.2%. Although findings were unrelated to age, they did correlate with compensatory sweating, which was found in 79.7% of patients undergoing synchronic bilateral sympathectomy, 78.5% of sequential bilateral sympathectomy patients and only 56.25% of unilateral sympathectomy patients.

CONCLUSIONS

Neuronal death and lipofuscin accumulation unrelated to inflammation are evident in sympathetic ganglia from patients with PPH. Such changes are atypical for a group of patients whose mean age is 29 years, unless such lesions are the result of functional hyperstimulation. Surgery performed sequentially does not lead to overloading of contralateral T2-T3 ganglia; on the contrary, decreased injury is evident.

[Sympathetic dermatomes corresponding to T2 and T3 ganglia. A prospective study of 100 superior thoracic sympathicolytic procedures]

The autonomic nervous system adjusts sweating on the body's skin surface. The skin areas corresponding to the various sympathetic ganglia are not yet clearly defined. The purpose of this study was to define the skin areas corresponding to the T2 and T3 sympathetic ganglia.

METHODS AND MATERIALS

We performed bilateral thoracic sympathicolysis endoscopically on the T2 and T3 ganglia of 50 patients with primary hyperhidrosis. All answered a questionnaire before surgery and at least two months later. The questionnaire asked about sweating at different points, but in order to estimate the cutaneous projection of T2 and T3 we only analyzed anhidrotic regions.

RESULTS

Denervation resulted in anhidrotic hands (98.11%); axillas (73.58%); arms (39.62%); forehead (20.75%); chin, cheeks, neck and the nape of the neck (16.98%); sides of the chest (13.2%); front of the chest (7.54%); and back (1.88%).

CONCLUSIONS

The territory influenced by the T2 and T3 sympathetic ganglia is more extensive than has been described by classical anatomical studies. The cutaneous area innervated by the sympathetic T2 and T3 ganglia extends to zones influenced by T1 in up to 20.75% of patients with primary hyperhidrosis.