Cardiopulmonary exercise testing following bilateral thoracoscopic sympathicolysis in patients with essential hyperhidrosis

Does endoscopic thoracic sympathectomy through clipping procedure have early effects on electrocardiographic parameters?

Background & objectives:

Hyperhidrosis is a pathologic condition of excessive sweating in amounts greater than physiologic needs. Endoscopic thoracic sympathectomy (ETS) is a globally accepted treatment modality for primary palmar and axillary hyperhidrosis. ETS also has distinctive effects on the heart, circulatory and respiratory systems. In this study early effects of ETS on electrocardiographic (ECG) parameters of hyperhidrosis patients were evaluated.

Methods:

Twelve-lead ECGs were performed on 72 patients who were free from cardiovascular, metabolic, neurological and pulmonary diseases and underwent planned ETS because of hyperhidrosis, before and after the procedure within the first 24 h. Heart rate (HR), PR, QT, corrected QT (QTc), QTc/Tpeak-Tend (TpTe) intervals, P-wave and QTc/TpTe dispersions were compared by ECG.

Results:

A total of 72 patients (24.1±6.0 yr, 17 female) were included in the study. The pre-operative HR of patients was significantly higher than post-operative HR of patients (73.8±12.8 vs. 68.1±12.6 beats/ min; P<0.001). The QTc dispersion (QTcd) durations of pre-operative patients were significantly longer than those of post-operative patients (51.5±6.3 vs. 44.9±5.6 msec; P<0.01). The TpTe dispersion value of pre-operative patients was significantly (P<0.001) higher than that of post-operative patients.

Interpretation & conclusions:

Our study showed that ETS through clipping procedure had positive effects on the mechanisms of arrhythmia by reducing HR, QTcd, TpTe and TpTe dispersion parameters of ECG in early periods in hyperhidrosis patients.

T2-T3 sympathectomy versus sympathicotomy for essential palmar hyperhidrosis: comparison of effects on cardio-respiratory function

OBJECTIVES

The aim of this study was to determine cardio-respiratory changes after endothoracic sympathetic denervation and their correlation with the extent of denervation.

METHODS

A total of 45 patients with essential palmar hyperhidrosis were randomized into two groups: the conventional group (CG; 23 patients) and the simplified group (SG; 22 patients). In the CG, excision of T2 and T3 ganglia was performed, whereas in the SG only separation of the sympathetic chain was performed at the same level. Patients underwent respiratory and cardiovascular exercise tests before, at 2 weeks and again at 6 months after the procedure. The postoperative values were then compared with the preoperative values to assess the statistical difference.

RESULTS

Twenty-one patients in each group completed the study. In the SG, forced expiratory volume in 1 s (FEV 1; P < 0.01) and forced vital capacity (FVC; P < 0.01) were significantly reduced at 2 weeks, but returned to similar baseline values 6 months after the procedure. No significant cardiac changes were observed. In the CG, both FEV 1 and FVC were significantly reduced at 2 weeks (P < 0.01) and at 6 months after operation (P < 0.05). A significant reduction in forced expiratory flow between 25 and 75% of vital capacity (P < 0.01) and a relevant increase in airway resistance (P < 0.05) during the entire postoperative course were also observed. Heart rates at rest and at peak exercise were significantly reduced at 2 weeks (P < 0.01) and significantly decreased 6 months after the procedure (P < 0.05). No other changes were registered. The cardio-respiratory alterations remained at a sub-clinical level; all patients completed the exercise test without symptoms.

CONCLUSION

Sympathectomy may result in a disturbance of bronchomotor tone and cardiac function. Such changes remained at a sub-clinical level and seemed directly correlated with the extension of denervation.

Hemodynamics following endoscopic thoracic sympathotomy for palmar hyperhidrosis

PURPOSE

We studied patients with palmar hyperhidrosis before and after endoscopic thoracic sympathotomy (ETS) to determine the effect of chronic sympathetic denervation on (1) forearm blood flow (FBF) response to mental stress and (2) exercise tolerance.

METHODS AND RESULTS

Twenty-two healthy patients were evaluated before ETS, and 17 returned after surgery (11 F; 19-32 years). We measured heart rate (HR; 12 lead), blood pressure, and FBF (plethysmography, ml dl(-1) min(-1)). Supine HR tended to decrease after ETS (69 ± 10 vs. 66 ± 6, p = 0.2). Mental stress FBF was recorded during baseline, 3-min Stroop color word test, and 2-min recovery. Mental stress responses were unaffected by ETS. However, during post-mental stress recovery period, ETS resulted in a significant elevation in FBF (2 ± 1 vs. 3 ± 1), FVC (3 ± 1 vs. 4 ± 2), and a decrease in FVR (52 ± 22 vs. 32 ± 16, p < 0.01 for all). ETS resulted in a reduction in pre-exercise seated baseline HR (94 ± 2.5 beats/min preoperatively vs. 84 ± 4.3 beats/min postoperatively, p < 0.05), maximal HR response to cycle exercise, and exercise systolic blood pressure (172 ± 5.2 mmHg pre-op vs. 158 ± 5.9 mmHg post-op, p < 0.05) but not mean or diastolic pressure. VO(2)max and exercise duration determined by cycle ergometry was unchanged.

CONCLUSIONS

Functional evidence of upper limb denervation is observed during the FBF recovery period from mental stress and hemodynamic alterations associated with upright cycle exercise. However, the sustained exercise capacity suggests modest clinical consequences.

Thoracic sympathectomy and cardiopulmonary responses to exercise

The purpose was to study the effect of endoscopic thoracic sympathectomy (ETS) for palmar and/or axillary hyperhidrosis on physiological responses at rest, and during sub-maximal and maximal exercise in ten healthy patients (7 females and 3 males 18-40 years old) with idiopathic palmar and/or axillary hyperhidrosis. T2-T3 thoracoscopic sympathectomy was performed using a simplified one stage bilateral procedure. Physiological variables were recorded at rest and during sub-maximal (steady-state) and maximal treadmill exercise immediately prior to and 70 days (+/-7.5, SD) after bilateral ETS. Exercise performance capacity and peak VO(2) were not found to be different following bilateral ETS than prior to the ETS. However, heart rate was significantly reduced at rest (14%), at sub-maximal exercise (12.3%), and at peak exercise (5.7%), together with a significant increase in oxygen pulse (11.8, 12.7, and 7.8%, respectively). The rate pressure product (RPP) was also significantly reduced following the surgical procedure at all three study stages, while all other physiological variables measured remained unchanged. It is suggested that thoracic-sympathetic denervation affects the heart, sweating, and circulation of the respective denervated region but does not affect exercise performance or mechanical/physiologic efficiency, despite a significant reduction in heart rate (both at rest and during exercise). The latter was, most likely, fully compensated by an increase in stroke volume and less likely by an improved muscle O(2) extraction due to more efficient blood distribution, keeping the work-rate and oxygen uptake unaffected.

[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.

Impaired left ventricular filling in patients with essential hyperhidrosis: an echo-Doppler study

Essential hyperhidrosis is a well recognized dermatologic and neurologic disorder, characterized by excessive sweating of the eccrine sweat glands. It is also associated with cardiac autonomic dysfunction because sympathetic fibers to eccrine glands of palms of the hand arise from stellate and upper thoracic ganglia, which also innervate the heart. In this study, we investigated cardiac function in patients with essential hyperhidrosis by conventional and tissue Doppler imaging methods. Eighteen subjects with essential hyperhidrosis and eighteen control subjects were included in this study. Pulsed-wave Doppler parameters of the left and right ventricles, which represent diastolic filling abnormalities, were obtained by conventional Doppler and tissue Doppler imaging. Isovolumetric relaxation time, isovolumetric contraction time, ejection time and myocardial performance index were also calculated. Mitral inflow peak early (E(M)) and late (A(M)) velocities and E(M)/A(M) ratio, which represent diastolic filling of left ventricle, were significantly lower in hyperhidrotic subjects than in controls. Also, mitral lateral annulus early and late velocities and early/late velocity ratio, reflecting diastolic filling of left ventricle, were significantly lower in hyperhidrotic subjects than those of controls. However, there were no differences between hyperhidrotic subjects and control subjects with regard to the other echocardiographic indices of left and right ventricle diastolic functions. In conclusion, decreased mitral inflow suggests left ventricle diastolic dysfunction in patients with essential hyperhidrosis. This indicates that hyperactivity of sympathetic nervous system in patient with hyperhidrosis may alter cardiac function in long term.

Video-Assisted Sympathectomy for Essential Hyperhidrosis

BACKGROUND

Essential hyperhidrosis is characterized by overactivity of the sympathetic fibers passing through the upper-dorsal ganglia (second and third thoracic ganglia [D2-D3]), and the treatment of choice is video-assisted thoracoscopy sympathectomy. Alterations in cardiopulmonary function after treatment have been reported.

STUDY OBJECTIVE

To evaluate cardiopulmonary function impairment after sympathectomy in patients with essential hyperhidrosis.

DESIGN AND SETTING

Prospective controlled trial at a pulmonary function unit of a university hospital.

PATIENTS

Twenty patients (2 men and 18 women) with essential hyperhidrosis.

MEASUREMENTS AND RESULTS

Pulmonary function tests, including spirometry and thoracic gas volume, bronchial challenge with methacholine, and maximal exercise, were performed before and 3 months after D2-D3 sympathectomy. Video-assisted sympathectomy was performed using a one-stage bilateral procedure with electrocoagulation of D2-D3 ganglia. Pulmonary function values (spirometrics and volumes) were not statistically different in the two groups. The maximal midexpiratory flow was the only variable that showed significant changes, from 101% (SD, 26%) to 92% (SD, 27%) [p < 0.05]. Ten patients had positive bronchial challenge test results that remained positive 3 months after surgery, and 2 patients whose challenge test results were negative before surgery became positive after sympathectomy. Significant reductions in maximal heart rate (HR) and oxygen and carbon dioxide uptakes were observed during the maximal exercise test.

CONCLUSIONS

Video-assisted thoracoscopy is a safe treatment, and the observed modifications in cardiopulmonary function only suggest a minimal small airway alterations in the presence of positive bronchial hyperresponsiveness and mild sympathetic blockade in HR. The clinical importance of these findings is not significant.

Effects of bilateral T2-sympathectomy on static and dynamic heart rate responses to exercise in hyperhidrosis patients

The static/dynamic changes of gas exchange, heart rate (HR) and blood pressure in terms of work rate (WR) and WR changes in ramp exercise were investigated by cardio-pulmonary exercise tests (CPETs) in hyperhidrosis patients before (W0), one week (W1) and four weeks (W4) after bilateral T2-sympathectomy. Accompanied by constant oxygen consumption and WR at peak exercise and similar oxygen debt in recovery, the HR significantly (p<0.05) decreased statically in all stages of CPET, but was not altered dynamically, i.e., similar slope but significantly diminished intercept in HR changes versus WR changes (70+/-6.0 vs. 82+/-19 beats/min, p<0.01), in W1 (n=11), compared to W0 (n=13). However, this surgical effect on static HR changes seemed to have disappeared in W4 (n=8), albeit at that time the static blood pressure decreased significantly during exercise. These findings suggest that bilateral T2-sympathectomy will reduce static HR without causing cardiovascular insufficiency in one week, and would then recover by one month in hyperhidrosis patients.

Heart rate variability in patients with essential hyperhidrosis: dynamic influence of sympathetic and parasympathetic maneuvers

BACKGROUND

Essential hyperhidrosis has been associated with an increased activity of the sympathetic system. In this study, we investigated cardiac autonomic function in patients with essential hyperhidrosis and healthy controls by time and frequency domain analysis of heart rate variability (HRV).

METHOD

In this study, 12 subjects with essential hyperhidrosis and 20 healthy subjects were included. Time and frequency domain parameters of HRV were obtained from all of the participants after a 15-minute resting period in supine position, during controlled respiration (CR) and handgrip exercise (HGE) in sitting position over 5-minute periods in each stage.

RESULTS

Baseline values of HRV parameters including RR interval, SDNN and root mean square of successive R-R interval differences, low frequency (LF), high frequency (HF), normalized unit of high frequency (HFnu), normalized unit of low frequency (LFnu), and LF/HF ratio were identical in two groups. During CR, no difference was detected between the two groups with respect to HRV parameters. However, the expected increase in mean heart rate (mean R-R interval) did not occur in hyperhidrotic group, whereas it did occur in the control group (Friedman's P = 0.000). Handgrip exercise induced significant decrease in mean R-R interval in both groups and no difference was detected between the two groups with respect to the other HRV parameters. When repeated measurements were compared with two-way ANOVA, there was statistically significant difference only regarding mean heart rate in two groups (F = 6.5; P = 0.01).

CONCLUSION

Our overall findings suggest that essential hyperhidrosis is a complex autonomic dysfunction rather than sympathetic overactivity, and parasympathetic system seems to be involved in pathogenesis of this disorder.

Hyperhidrosis: evolving therapies for a well-established phenomenon

The socially embarrassing disorder of excessive sweating, or hyperhidrosis, and its treatment options are gaining widespread attention. In order of frequency, palmar-plantar, palmar-axillary, Isolated axillary, and cranlofacial hyperhidrosis are distinct disorders of sudomotor regulation. A common link among these disorders is an excessive, nonthermoregulatory sweat response often to emotional stimuli in body regions influenced by the anterior cingulate cortex as opposed to the thermoregulatory sweat response regulated by the preoptic-anterior hypothalamus. Diagnosis of these mechanistically ambiguous disorders is primarily from patient history and physical examination, whereas results of laboratory studies performed with indicator powder reveal the distribution and severity of resting hyperhidrosis and document the integrity of thermoregulatory sweating. Treatment options lie on a continuum based on the severity of hyperhidrosis and the risks and benefits of therapy. In general, therapy begins with antiperspirants or anticholinergics. Iontophoresis is available for palmar-plantar and axillary hyperhidrosis. Botulinum toxin type A or local excision/curettage is effective for isolated axillary hyperhidrosis not responsive to topical application of aluminum chloride. Endoscopic thoracic sympathectomy may be used for severe cases of palmar-plantar and palmar-axillary hyperhidrosis. No sole therapy of choice has emerged for craniofacial sweating. The long-term sequelae of hyperhidrosis and its treatment also are discussed.

Peripheral Vascular Endothelial Function in Essential Hyperhidrosis

BACKGROUND

Essential hyperhidrosis, a disorder of the eccrine sweat glands, is associated with sympathetic overactivity and the aim of the present study was to determine endothelium-dependent vasodilator function in patients with this condition.

METHODS AND RESULTS

Using high-resolution ultrasound, the diameter of the brachial artery at rest and during reactive hyperemia (flow-mediated dilatation, %FMD endothelial-dependent stimulus to vasodilatation), as well as after sublingual administration of nitroglycerin (%NTG endothelium-independent vasodilatation) was measured in 18 subjects (mean age 27+/-5 years) with essential hyperhidrosis and 24 healthy control subjects (mean age 29+/-5 years). Baseline brachial artery diameter and FMD were comparable in both groups (BAD: 4.1+/-0.7 mm vs 4.3+/-0.5 mm (control), p = 0.8; FMD: 5.6+/-1.9% vs 6.7+/-2.2%, p=0.1). The time-averaged flow velocity during peak reactive hyperemia was similar in the 2 groups (75+/-11 cm/s vs 72+/-10 cm/s, p = 0.5), nor did NTG-induced dilatation in the patients with essential hyperhidrosis differ significantly from that in healthy control subjects (12.8+/-2.7% vs 14.0+/-3.6%, p = 0.3).

CONCLUSION

These findings suggest that endothelium-dependent dilatation of large conduit arteries is preserved in essential hyperhidrosis and it seems to be a localized disorder of the eccrine sweat glands rather than a generalized disorder involving vascular endothelium.

Efeitos da simpaticotomia endoscópica sobre as artérias carótidas e vertebrais na terapêutica cirúrgica da hiperidrose primária

OBJETIVOS: Analisar, em pacientes submetidos a simpaticotomia videotoracoscópica para tratamento da Hiperidrose Primária (HP), as conseqüências hemodinâmicas da desnervação vascular das artérias carótidas e vertebrais após a trans-secção cirúrgica da cadeia simpática torácica (simpaticotomia), através da mensuração de parâmetros ultra-sonográficos. MÉTODO: Vinte e quatro pacientes portadores de HP submetidos a quarenta e oito simpaticotomias torácicas endoscópicas foram avaliados através da mensuração da velocidade de pico sistólico (VPS), velocidade de pico diastólico (VPD), índice de pulsatibilidade (IP) e índice de resistência (IR) nas artérias carótidas comuns, internas e externas, além da artéria vertebral bilateralmente usando o eco-doppler duplex scan. As avaliações foram realizadas antes da intervenção cirúrgica e trinta dias após o procedimento. O teste de Wilcoxon foi usado na análise das diferenças entre as variáveis antes e depois da simpaticotomia. RESULTADOS: A simpaticotomia no nível de T3 foi a trans-secção mais realizada (95,83%), seja isoladamente (25%) ou associada a T4 (62,50%) ou a T2 (8,33%). Houve aumento significativo no IR e no IP da artéria carótida comum bilateralmente (p<0,05). A VPD da artéria carótida interna diminuiu em ambos os lados (p<0,05). A VPS e a VPD da artéria vertebral direita também aumentaram (p<0,05). Achados assimétricos foram observados, de modo que artérias do lado direito foram as mais freqüentemente afetadas. CONCLUSÕES: Alterações hemodinâmicas foram observadas nas artérias vertebral e carótida após simpaticotomia para tratamento de HP. VPS foi o parâmetro mais freqüentemente alterado, principalmente nas artérias do lado direito, representando alterações assimétricas significantes nas artérias carótida e vertebral. Entretanto, são necessárias pesquisas subseqüentes para verificar se essas alterações são definitivas ou temporárias, uma vez que as inferências clínicas somente terão validação se as alterações forem permanentes.

[Our experience in the treatment of hyperhidrosis of the upper limbs by video-assisted thoracoscopy: an analysis of our first 100 procedures]

Sympathectomy of the thoracic chain is an effective surgical procedure for treating axillary and palmar hyperhidrosis. The procedure has been performed with minimal invasion and good results in recent years through the use of videothoracoscopic surgery. This paper describes the technique and our experience with a series of 50 patients between 16 and 48 years old. The earliest approach was unilateral in successive operations. The procedure was later performed bilaterally, at first with the patients in sequential lateral decubitus positions and later in semi-seated position. Complications were 1 case of incomplete Claude-Bernard-Horner syndrome that resolved spontaneously two months after surgery; 1 failure when sympathectomy was performed without location of the chain, obliging rapid re-operation; laminar pneumothorax in 12% of the series; compensatory hyperhidrosis in 26%; 10% with chest pain due to intercostal involvement, resolving with time; and slight bleeding in 8%. Outcome was excellent, with complete disappearance of axillary and palmar perspiration. Patient satisfaction was 9.2/10 one year after surgery. Mean hospital stay was less than 36 h.

Infra-stellate upper thoracic sympathectomy results in a relative bradycardia during exercise, irrespective of the operated side

OBJECTIVE

Removal of accessory fibres coming from the sub-stellar thoracic chain to the heart during infra-stellate surgical upper thoracic sympathectomy (ISS) may be responsible for a decreased heart rate to workload relationship during exercise following surgery. We hypothesised that heart rate would decrease not only following right ISS.

METHODS

We performed repeated bicycle incremental exercise tests in 11 control subjects (26.9+/-9.5 years, 61.4+/-12.4 kg, 167+/-10 cm), and 11 patients (29.8+/-10 years, 59.3+/-12.0 kg, 168+/-7 cm) referred for bilateral ISS: results are mean+/-standard deviation. Surgery was performed at two distinct times allowing to study the consequences of unilateral and bilateral sympathectomy to confirm whether a significant relative bradycardia was constant and dependent on the operated side.

RESULTS

For control subjects, test durations were 13.55+/-3.29, 14.09+/-4.01 and 13.00+/-3.26 min and heart rates were 187+/-7, 187+/-8 and 186+/-7 beats min(-1) at the first, second and third test, respectively. Although time to exhaustion was comparable to controls and unchanged between tests: 12.32+/-2.87, 12.3+/-2.90, 12.33+/-3.76 min, heart rate at maximum exercise decreased significantly from 176+/-16 to 164+/-15, and 148+/-15 beats min(-1), before, following unilateral and bilateral ISS, respectively. The operated side did not allow for the prediction of the effect of unilateral sympathectomy.

CONCLUSIONS

Patients should be informed of the exercise bradycardia resulting from ISS, although clinical tolerance seems excellent in endurance exercise. Contrary to previous reports at rest, during exercise no right-sided dominance was observed. These findings are consistent with reports of random distribution of sub-stellate cardiac fibres from anatomical studies.

Thoracoscopic sympathectomy for palmar hyperhidrosis: effects on pulmonary function

Palmar hyperhidrosis, probably caused by an over-reactivity of sympathetic nerves passing through the second and the third thoracic sympathetic ganglia (T2 & T3 ganglia), can only be cured by sympathectomy. Such sympathetic denervation may also alter pulmonary function. Previous studies have shown that open sympathectomy can cause significant deterioration in pulmonary function, however, the surgical procedure itself may contribute to the change. Recently thoracoscopic sympathectomy has been developed as a minimally invasive but effective treatment for palmar hyperhidrosis. In order to investigate the effect of sympathectomy, pulmonary function was compared before and four weeks after operation in 20 patients. Forced vital capacity (FVC) (-2.3%), forced expiratory volume in one second (FEV1) (-6.1%), and FEV1/FVC (-4.6%) were all slightly but significantly decreased four weeks after thoracoscopic sympathectomy. Also the instantaneous forced expiratory flow at 75%, 50% and 25% of the FVC (Vmax25, Vmax50, Vmax75) in flow-volume curves were decreased (-1.6%, -8.4%, and -20% respectively). Therefore, thoracoscopic sympathectomy minimises pulmonary restrictive effects but allows subclinical small airway obstructive effects to become more evident.

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.

Endoscopic thoracic sympathectomy

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. In a previously published series the authors performed 60 thorascopic procedures in 39 patients; in this paper, they report the addition of 52 procedures performed in 26 patients, for a total of 112 procedures in 65 patients. Overall, the outcomes were equivalent to those for previously established 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 repeat 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. Minimally invasive thoracoscopic sympathectomy procedures are useful in treating sympathetically mediated disorders, and the results indicated 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.

Endoscopic thoracic sympathectomy for primary palmar hyperhidrosis: intermediate term results

BACKGROUND

The authors' experience of the efficacy and safety of endoscopic thoracic sympathectomy in the treatment of primary palmer hyperhidrosis was examined.

METHODS

A retrospective study of 71 patients (126 sympathectomies) was undertaken. Data were retrieved by hospital records and telephone interview.

RESULTS

Follow-up was possible for 92 sympathectomies in 53 patients. Overall, satisfactory results were achieved in 93% of patients and complications were uncommon. Compensatory hyperhidrosis was the most common complication, which occurred in 64% of patients; the trunk and feet were the most common sites. Horner's syndrome occurred in five patients, although in two it was a permanent complication. No patient expressed dissatisfaction with the procedure as a consequence of this complication. Pneumothorax occurred in 17.5% of cases, although the vast majority were incidental findings on a postoperative chest X-ray, and none required drainage. With the newer techniques of access, patient dissatisfaction with the cosmetic appearance has fallen from 27.3 to 6.4%. Overall 90% of patients said they would have the operation again, which represents a high level of patient satisfaction.

CONCLUSIONS

Endoscopic thoracic sympathectomy is a safe and effective technique for primary palmer hyperhidrosis. Evolution of the technique has resulted in improvement in patient satisfaction.

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.

Thoracoscopic sympathectomy: techniques and outcomes

Thoracic sympathectomy is an important option in the treatment of palmar hyperhidrosis and pain disorders. Earlier surgical procedures were highly invasive with known morbidity, acceptable outcome, and established recurrence rates that were the limitations to considering surgical treatment. Thoracoscopic sympathectomy is a minimally invasive procedure that allows detailed visualization of the sympathetic ganglia and minimal postoperative morbidity; however, outcome studies of this technique have been limited. The authors treated 39 patients with 60 thoracoscopic procedures, and the outcomes in this small series were equivalent to previously established open surgical techniques; however, operative moribidity rates, hospital stay, and time of return to normal activity were substantially reduced. Complications and recurrence of symptoms were also comparable to previous reports. Overall patient satisfaction and willingness to repeat the operative procedure ranged from 66 to 96% in all patients. Patients and physicians can consider minimally invasive thoracoscopic sympathectomy procedures as an option to treat sympathetically mediated disorders because of the procedure's reduced morbidity and at least equivalent outcome rates in comparison to other treatments.

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.

Effects of non-pharmacological sympathetic sudomotor denervation on sweating in humans with essential palmar hyperhidrosis

OBJECTIVE

Quantitative sweat production and -ionic composition in Essential Hyperhidrosis (EH), and the effects of T2-T3 thoracoscopic sympathicolysis (TS) hereon, are unknown. Standardised pilocarpine iontophoresis sweat tests were performed before and after TS in order to study these issues.

DESIGN AND METHODS

Pilocarpine iontophoretic sweat tests measuring maximal sweat production (mg) and sweat Na+, K+ and Cl- concentrations (mMol/L) were performed on both forearms of 10 EH patients, before and six weeks after TS, and in normal volunteers.

RESULTS

As compared to normals, preoperative maximal sweat production was 30% higher (199.4 +/- 68.8 (SD) vs. 150.6 +/- 45.6 mg) in EH patients; due to type II error, however, statistical significance was not reached. Na+ and Cl- concentrations were similar, and K+ concentration was slightly lower in EH patients. After TS, sweat production had decreased to equal levels as in normals (149.1 +/- 52.1 mg), whereas the Na+ (from 33.6 +/- 6.9 to 51.0 +/- 6.4 mMol/L), Cl- (from 21.5 +/- 6.6 to 37.2 +/- 7.1 mMol/L) and K+ (from 7.5 +/- 1.3 to 8.6 +/- 2.2 mMol/L) concentrations had increased.

CONCLUSIONS

EH patients present 30% higher maximal sweat production at their forearms. This increase may be due to an increased activity of the adrenergic component of sweat gland innervation. The post-TS increase in Na+, Cl- and K+ concentrations suggests that the adrenergic component of sweat gland innervation in itself decreases sweat ion concentrations.

Changes in cardiocirculatory autonomic function after thoracoscopic upper dorsal sympathicolysis for essential hyperhidrosis

Essential hyperhidrosis (EH) is caused by an unexplained overactivity of the sympathetic fibers which pass through the upper dorsal sympathetic ganglia D2 and D3. Since the D2 and D3 ganglia are also involved in the sympathetic cardiac innervation, cardiocirculatory autonomic function may also be abnormal in EH. In order to study the function of the sympathetic nervous system in EH, and to assess the effects of thoracoscopic sympathiocolysis, cardiocirculatory autonomic function tests were performed in 13 consecutive patients with EH, before (baseline) and 6 weeks after the thoracoscopic intervention. Baseline data were also compared with data obtained from 13 matched healthy volunteers: EH patients showed an increased heart rate at rest, but only in the standing position (94 +/- 18.5 vs 78 +/- 10.9 bpm, P < 0.01), as well as an increased ratio of low to high frequency power of the heart rate variability in the standing position (5.92 +/- 4.4 vs 2.8 +/- 2.5, P < 0.05). Exercise tests were normal in every EH patient. After sympathiocolysis, heart rate at rest (sitting on the cycloergometer) had decreased (75.4 +/- 13 vs 90.4 +/- 16.5 bpm, P < 0.05), as well as heart rate at maximal exercise (165.2 +/- 14.8 vs 180 +/- 10 bpm, P < 0.05). Exercise capacity and the cardiorespiratory responses to exercise were, however, unchanged after sympathicolysis. Resting heart rate in the lying (66 +/- 10 vs 76 +/- 15 bpm, P < 0.05) and standing positions (82 +/- 13.8 vs 94 +/- 18.5 bpm, P < 0.05), and the diastolic blood pressure reaction to a handgrip test (73.6 +/- 8.6 vs 84.7 +/- 11.6 mmHg, P < 0.05) were also lowered after sympathicolysis. In conclusion, patients with EH show an overfunctioning of the sympathetic system which is characterised by an increased reaction to stress (standing, exercise), whereas resting sympathetic tone is unaffected. Thoracoscopic D2-D3 sympathicolysis corrects this hyperfunction and has a partial beta-blocker-like activity, which results in a decrease in heart rate at rest and during maximal exercise, and in the diastolic blood pressure response to the handgrip test. Further studies are needed to assess the long-term consequences of this procedure.