Endoscopic electrocautery of the thoracic sympathetic chain. A minimally invasive way to treat palmar hyperhidrosis

Minimally Invasive Sympathicotomy for Palmar Hyperhidrosis and Facial Blushing: Current Status and the Hyperhidrosis Expert Center Approach

Hyperhidrosis, the medical term for excessive sweating beyond physiological need, is a condition with serious emotional and social consequences for affected patients. Symptoms usually appear in focal areas such as the feet, hands, axillae and face. Non-surgical treatment options such as topical antiperspirants or systemic medications are usually offered as a first step of treatment, although these therapies are often ineffective, especially in severe and intolerable cases of hyperhidrosis. In the treatment algorithm for patients suffering from hyperhidrosis, surgical thoracoscopic sympathicotomy offers a permanent solution, which is particularly effective in the treatment of palmar hyperhidrosis and facial blushing. In this review, we describe the current status of thoracoscopic sympathicotomy for palmar hyperhidrosis and facial blushing. In addition, we share the specific treatment approach, technique and results of our Hyperhidrosis Expert Center. Last, we share recommendations to ensure an effective, reproducible and safe application of single-port thoracoscopic sympathicotomy for palmar hyperhidrosis and facial blushing, based on our extensive experience.

Reoperation for Essential Hyperhidrosis

Palmar hyperhidrosis has a recurrence rate of 0% to 5% after thoracic sympathectomy. From January 1992 to October 1997, thoracic sympathectomy was performed by video-assisted thoracoscopic surgery for hyperhidrosis in 490 patients of whom 5 (2 male and 3 female with a mean age of 20 years) experienced recurrent hyperhidrosis in the early (< 7 days) or late (up to 6 months) postoperative period. All patients had moderate to severe pleural adhesions in the previous sympathectomy sites but no operative complications or crossover to thoracotomy occurred. Surgery resulted in satisfactory outcomes showing that video-assisted thoracoscopic sympathectomy was effective in treating recurrent hyperhidrosis. Prevention of recurrence requires the identification and resection of the second thoracic sympathetic ganglion as well as the Kuntz fibers.

Thoracoscopic sympathectomy for palmar hyperhidrosis

BACKGROUND

Upper thoracoscopic sympathectomy, obtained either by ablation or resection of the appropriate ganglia, is now the preferred treatment for primary palmar hyperhidrosis. Therefore, we undertook a review to compare the relative efficacy of these two techniques.

METHODS

A Medline search was performed for the years 1974-99 to identify all published studies of thoracoscopic sympathectomy for hyperhidrosis.

RESULTS

In all, 33 studies were identified and divided into two groups-ablation and resection. When the resection method was used, the immediate success rate was 99.76%, whereas the ablation method achieved dry hands in 95.2% of cases (p = 0.00001). Palmar sweating recurred in 0% of patients treated via resection and -4.4% treated with ablation. Ptosis was noted in 0.92% of cases after ablation and in 1.72% after resection (p = 0.017).

CONCLUSIONS

Resection yields superior results, yet the majority of surgeons ablate, probably because it is easier, requires a shorter operating time, leads to fewer cases of Horner's syndrome, and because resympathectomy eventually overcomes initial failure.

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.

Comparing T2 and T2–T3 ablation in thoracoscopic sympathectomy for palmar hyperhidrosis: a randomized control trial

BACKGROUND

Thoracoscopic sympathectomy is a useful therapeutic option for palmar hyperhidrosis. Surgeons differ in the level of the sympathetic chain ablated. This study aimed to compare the blockade of the T2 with levels T2 and T3 to verify the effectiveness of different ablation levels in relieving hyperhidrosis symptoms.

METHODS

For patients undergoing bilateral thoracoscopic sympathectomy for palmar hyperhidrosis, T2-T3 ablation is performed bilaterally. In our series, 25 consecutive patients were blindly randomized to undergo unilateral T2 and T3 ablation followed by contralateral ablation of level T2 only. The patients were followed up and analyzed for comparison of symptoms bilaterally, compensatory hyperhidrosis, and levels of satisfaction postoperatively.

RESULTS

The study group consisted of 25 patients with a male:female ratio of 3:2 and a mean age of 32 years (range, 19-50 years). The mean operative time was 35 min. The patients were followed up for a mean period of 23 months (range, 2-65 months). All 25 patients confirmed that their palmar sweating resolved postoperatively, with both palms equally dry. Of the 25 patients, 20 (80%) complained of compensatory hyperhidrosis, which also was bilaterally symmetric. The areas involved were trunk (80%), lower limbs (32%), and armpits (12%). Overall, 80% of the patients were very satisfied with the procedure. The remaining 20% experienced mild to moderate compensatory hyperhidrosis, which did not seem to affect their lifestyle.

CONCLUSION

The findings show that T2 ablation in thoracoscopic sympathectomy for palmar hyperhidrosis is as effective as T2-T3 ablation in terms of symptomatic relief, recurrence, compensatory hyperhidrosis, and patient satisfaction.

Facial blushing treated by sympathetic denervation--longlasting benefits in 831 patients

BACKGROUND

Severe facial blushing may have a strong negative impact on the quality of life and is one of the cardinal symptoms of social phobia. If traditional therapeutic options such as psychotherapy and pharmacological treatment fail, interruption of the sympathetic innervation to the face offers good results, however long-term results may not be good.

AIM

To investigate whether endoscopic thoracic sympathecotomy (ETS) remains an effective treatment of facial blushing more than one year's follow up.

METHOD

1314 consecutive patients with severe facial blushing were treated with bilateral ETS. The results were evaluated by questionnaire and symptoms assessed with visual analogue scales (0-10).

RESULTS

The questionnaire was completed by 831 patients (63%) a mean of 29 months (+/- 11 days) after surgery. Facial blushing was reduced from 8.8 +/- 0.05 to 2.5 +/- 0.09, P < 0.0001 by the operation. The quality of life was substantially improved. The main side-effect was redistribution of sweating from the upper to the lower part of the body (compensatory sweating). Increased sweating of the trunk occurred in 83% of the responses. Overall, 85% of the respondents were satisfied with the result and 15% were to some degree not satisfied.

CONCLUSIONS

As this is an open study and 37% of patients did not respond to the questionnaire, the results must be viewed with caution. ETS, however, appears to be an effective, safe and lasting surgical method for the treatment of severe facial blushing. Side-effects, especially compensatory sweating on the trunk and legs are common, and may be severe but only rarely result in the patient regretting the operation.

Cervico-thoracic ganglion: Its clinical implications

Lesions of the cervicothoracic ganglion (CTG) result in interruption of sympathetic fibers to the head, neck, upper limb, and thoracic viscera. The accurate understanding of the anatomy of the CTG is relevant to sympathectomy procedures that may be prescribed in cases where conventional intervention has failed. This study documents the incidence and distribution of the CTG to avoid potential complications such as Horner's syndrome and cardiac arrhythmias. This study utilized 48 cadavers, in which a total of 89 sympathetic chains were dissected. The inferior cervical ganglion (ICG) and the first thoracic ganglion was fused in 75 cases (84.3%) to form the CTG. It was present bilaterally in 48 of these specimens (65.3%). Three different shapes of CTG were differentiated, viz. spindle, dumbbell, and an inverted "L" shape. The dumbbell and inverted "L" shapes demonstrated a definite "waist" (i.e., a macroscopically visible union of the ICG and T1 components of the CTG). Rami from the CTG was distributed to the brachial plexus, the subclavian and vertebral arteries, the brachiocephalic trunk, and the cardiac plexus. This study demonstrates a high incidence of a double cardiac sympathetic nerve arising from CTG. It is therefore imperative that in the technique of sympathectomy, for intractable anginal pain, the surgeon excises both these rami but does not destroy the ganglion itself. The ever-improving technology in endoscopic surgery has made investigations into the nuances of the anatomy of the sympathetic chain essential.

Effect of Endoscopic Transthoracic Sympathicotomy on Plasma Natriuretic Peptide Concentrations in Humans

BACKGROUND

The effects of endoscopic transthoracic sympathicotomy (ETS) on plasma natriuretic peptides concentrations in humans were examined in order to elucidate the role of the sympathetic nervous system in their regulation.

METHODS AND RESULTS

Thirty-seven patients with palmar hyperhidrosis underwent ETS. Cardiac functional indices were assessed by echocardiography, and plasma atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) concentrations were measured before and after ETS. ETS caused decreases in heart rate, mean arterial pressure, systemic vascular resistance, and increases in left ventricular (LV) end-diastolic volume, stroke index, ejection fraction, and left atrial diameter. LV end-systolic volume and cardiac index remained unchanged. Following ETS, ANP increased from 10.7+/-5.9 to 24.7+/-16.8 pg/ml (p < 0.01), and BNP increased from 5.1+/-4.2 to 19.7+/-21.5 pg/ml (p < 0.01). From the multivariate regression analysis, ETS, age and gender were determined to be significant predictors of changes in the ANP and BNP concentrations. None of the hemodynamic parameters were useful as independent predictors.

CONCLUSION

The plasma concentrations of ANP and BNP increased after ETS, independent of hemodynamic changes, and apparently because of the release of the inhibitory effects of the cardiac sympathetic nerves on natriuretic peptide secretion.

Role of video-assisted thoracoscopic sympathectomy in the treatment of primary hyperhidrosis

CONTEXT

Essential hyperhidrosis is a frequent disorder causing significant functional impairment. The advent and development of video-assisted thoracoscopic techniques now allows thoracic sympathectomy to be carried out precisely and safety with good results and minimal morbidity.

OBJECTIVE

To assess the impact of video-assisted thoracic sympathectomy in patients diagnosed as presenting severe and disabling hyperhidrosis.

TYPE OF STUDY

This was a longitudinal study of the clinical course of all hyperhidrosis cases selected for surgery between May 1999 and January 2003.

SETTING

Division of Thoracic Surgery, Universidade Federal de S o Paulo (UNIFESP).

PARTICIPANTS

743 patients with surgery indicated due to palmar hyperhidrosis (49.8%), palmar-axillary hyperhidrosis (38.1%), craniofacial hyperhidrosis (8.9%) or isolated axillary hyperhidrosis (2.8%).

PROCEDURES

Video-thoracoscopic sympathectomy was performed, isolating the second thoracic ganglion (T2) in all patients, with additional sympathectomy of T3 and T4 if necessary.

MAIN MEASUREMENTS

The clinical course was followed up via questionnaires, phone calls, letters and statements. Simple questions were asked regarding the disappearance of symptoms and presence and intensity of compensatory sweating.

RESULTS

The surgery was regarded as efficient in all cases of palmar hyperhidrosis. In the craniofacial hyperhidrosis cases, partial recurrence of the symptoms occurred in 2 cases (3.0%). Partial recurrence or persistence of symptoms occurred in 20% of the patients with predominantly axillary symptomatology. The compensatory sweating was considered disagreeable or uncomfortable by about 30% of the patients, but it only reached the level of regretting the operation for 3% of them. This occurred more frequently in patients with axillary hyperhidrosis. Ten cases of complications occurred.

CONCLUSION

Thoracoscopic sympathectomy provides very good results in most patients, with a very low complication rate. However, the assessment of surgical results using conventional methods is imprecise and inaccurate. Different methodology, including quality of life assessment, must be used for comparing results and providing objective data on the results of this operation.

The sympathetic contributions to the cardiac plexus

Cardiac sympathetic denervation for intractable angina pectoris in patients unsuitable for conventional revascularization is currently gaining popularity since this procedure may be performed via minimally invasive surgery. A thorough understanding of cardiac innervation and its variations is crucial to successfully effect cardiac denervation. This study aimed to demonstrate the cervical and thoracic sympathetic contributions to the cardiac plexus. The cervical and thoracic sympathetic trunks in 21 fetuses and eight adults were micro-dissected bilaterally and documented ( n=58 sides). The superior cervical cardiac ramus originated from the superior cervical ganglion (present in all specimens) in 53% of cases. The middle cervical ganglion (incidence 81%) gave rise to the middle cervical cardiac ramus in 88% of cases. The cervico-thoracic ganglion (incidence 85%) gave the cervico-thoracic cardiac ramus in 84%. In the thoracic region, four cardiac rami arose from the T2-T6 segment of the thoracic sympathetic trunk. All cervical and thoracic cardiac rami were traced consistently to the deep cardiac plexus. Khogali et al.'s (1999) success of limited T2-T4 sympathectomy in relieving pain at rest of patients with intractable angina pectoris appears to indicate that a significant afferent pain pathway from the heart is selectively interrupted. The variability in pattern of the cervical ganglia, cardiac rami and cervical contributions to the cardiac plexus does not appear to affect the outcome of limited sympathectomy. The complexity of cardiac pain pathways is not fully understood. The study is continuing and attempts to contribute to defining these cardiac neuronal pathways.

Circuits and projections of cat stellate ganglion

BACKGROUND

Although connections of stellate ganglion (SG) have been widely explored, some features of pathways and projections remain unknown, such as the source and fate of preganglionic axons present in output branches, including both synaptically interrupted and traversing pathways as well as axon composition (efferent and afferent) of these output nerves.

METHODS

Circuits and central projections of cat SG were investigated using horseradish peroxidase (HRP) tracer and electrophysiologic techniques including stimulation of ganglionic branches during recording of genesis of compound action potentials in other nerves or centrally evoked responses.

RESULTS

All branches of SG including vertebral nerve are mixed, i.e., they contain axons that synapse in the periphery or traverse ganglia. A novel synaptically interrupted pathway bi-directionally coursing along subclavian branches and inferior cardiac nerve was identified. Preganglionic axons traversing stellate ganglion course in communicating branch to vagus nerve and to inferior cardiac nerve, a small number of these preganglionic axons traversing stellate ganglion reach cervical sympathetic trunk via subclavian branches. For the first time, a small number of preganglionic traversing pathways were also detected in vertebral nerve. Afferent axons with somata located in C8-T7 dorsal root ganglia, identified in all branches of SG, projected centrally to neurons in thalamus and somatosensory zones of cerebral cortex and coincided with afferent projections of brachial plexus.

CONCLUSIONS

Present data contribute to the morphologic description of autonomic regulation of thoracic organs, including centrally independent peripheral autonomic axon reflexes.

Effects of endoscopic transthoracic sympathicotomy on hemodynamic and neurohumoral responses to exercise in humans

Endoscopic transthoracic sympathicotomy (ETS) is a minimal invasive procedure of thoracic sympathetic block and has been used successfully in the treatment of primary palmar hyperhidrosis. To examine the effect of Th 2-3 ETS on hemodynamic responses to submaximal upright treadmill exercise in humans, cardiac output, plasma noradrenaline and adrenaline at rest and during the last 40s of stage 2 in a modified Bruce protocol were measured before and after ETS in 21 patients with primary palmar hyperhidrosis. Heart rate, mean arterial pressure, rate-pressure product, and noradrenaline decreased at rest and at submaximal exercise after ETS. Cardiac index at rest did not change either before or after ETS, but decreased (8.9 +/- 0.6 vs 6.8 +/- 0.4L x min(-1) m-2; p<0.01, mean +/- SEM) at submaximal exercise after ETS. Stroke index and systemic vascular resistance were similar both at rest and at submaximal exercise before and after ETS. Thus, ETS reduces myocardial oxygen demand and plasma noradrenaline levels both at rest and during exercise without significantly depressing cardiac function in terms of stroke volume.

Palmar hyperhidrosis: evidence of genetic transmission

BACKGROUND

Primary palmar hyperhidrosis is a condition marked by excessive perspiration and is reported to have an incidence of 1% in the Western population. It is a potentially disabling disorder that interferes with social, psychological, and professional activities. Over the past several years, several investigators have reported a positive family history in their patients treated for hyperhidrosis. To date, the cause is unknown; furthermore, epidemiologic data are scarce and inadequate.

METHODS

To characterize the genetic contribution to hyperhidrosis, we conducted a prospective study of 58 consecutive patients with palmar, plantar, or axillary hyperhidrosis treated with thoracoscopic sympathectomy from September 1993 to July 1999. Forty-nine of the 58 probands volunteered family history data for these analyses (84% response rate). A standardized questionnaire was administered during the postoperative visit or by phone interview, and a detailed family history was obtained. The same questionnaire was also administered to a set of 20 control patients. The familial aggregation of hyperhidrosis has been quantified by estimating the recurrence risks to the offspring, parents, siblings, aunts, uncles, and cousins of 49 probands and 20 controls. We estimated the penetrance by use of a genetic analysis program.

RESULTS

Thirty-two of 49 (65%) reported a positive family history in our hyperhidrosis group, and 0% reported a positive family history in our control group. A recurrence risk of 0.28 in the offspring of probands compared with frequency of 0.01 in the general population provides strong evidence for vertical transmission of this disorder in pedigrees and is further supported by the 0.14 risk to the parents of the probands. The results indicate that the disease allele is present in about 5% of the population and that one or two copies of the allele will result in hyperhidrosis 25% of the time, whereas the normal allele will result in hyperhidrosis less than 1% of the time.

CONCLUSIONS

We conclude that primary palmar hyperhidrosis is a hereditary disorder, with variable penetrance and no proof of sex-linked transmission. However, this does not exclude other possible causes, and we anticipate that genetic confirmation of this disorder may lead to earlier diagnoses and advances in medical and psychosocial interventions.

Posterior approach for the simultaneous, bilateral thoracoscopic sympathectomy

If there is an indication for sympathectomy in the case of severe hyperhidrosis or rubeosis, in our opinion the posterior approach is preferable because of the advantages in surgical technique and anesthesia. Bilateral treatment can be accomplished in a single admission, with all the concomitant advantages.

The treatment of primary palmar hyperhidrosis: a review

Primary palmar hyperhidrosis (HH) is a pathological condition of overperspiration caused by excessive secretion of the eccrine sweat glands, the etiology of which is unknown. This disorder affects a small but significant proportion of the young population all over the world. Neither systemic nor topical drugs have been found to satisfactorily alleviate the symptoms. Although the topical injection of botulinum has recently been reported to reduce the amount of local perspiration, long-term results are required before a definitive evaluation of this method can be made. Hypnosis, psychotherapy, and biofeedback have been beneficial in a limited-number of cases. While radiation achieves atrophy of the sweat glands, its detrimental effects prohibit its use. Iontophoresis has attained some satisfactory results but it has not been assessed long term. Percutaneous computed tomography-guided phenol sympathicolysis achieves excellent immediate results, but its long-term failure rate is prohibitive. Furthermore, percutaneous radiofrequency sympathicolysis may be an effective procedure, but its long-term results are not superior to surgical sympathectomy. On the other hand, surgical upper dorsal (T2-T3) sympathectomy achieves excellent long-term results and the thoracoscopic approach has supplanted the open procedures. Despite some sequelae, mainly in the form of neuralgia and compensatory sweating which cannot be predicted and may be distressing, surgical sympathectomy remains the best treatment for palmar hyperhidrosis.

Uniportal endoscopic superior thoracic sympathectomy

OBJECTIVE

A retrospective study presenting our experience with upper thoracic endoscopic sympathectomy in patients with primary palmar hyperhidrosis.

METHODS

One hundred patients (46 women and 54 men) underwent bilateral uniportal endoscopic thoracic sympathectomy since January 1, 1995. Age distribution ranged from 12 to 54 years (mean, 23.4 yr).

RESULTS

Sympathectomy on both sides was accomplished within 30 minutes in a single stage. Ninety-six patients (96%) had an uneventful postoperative course and were discharged the following day. Four patients with residual hemothorax required intercostal drainage and were discharged on the third postoperative day. Ninety-six patients were completely satisfied with immediate and permanent relief of palmar perspiration. Compensatory hyperhidrosis was the major complication, which was usually mild and tolerable after reassurance. In only eight patients (8%) was the compensatory hyperhidrosis considered bothersome, requiring treatment with aluminum chloride in ethanol solution at 25%. There was no mortality. Recurrence of palmar hyperhidrosis has been noticed in five patients (5%) during the follow-up period (range, 2-56 mo; mean, 12 mo). At the time of reoperation, a remaining branch of the sympathetic chain could be observed and coagulated.

CONCLUSION

We consider thoracoscopic sympathectomy to be a simple, safe, and effective method for treating palmar hyperhidrosis. It is an effective method for treating patients with palmar hyperhidrosis, with a shorter operation time, fewer hospital days, and a better cosmetic result, as compared with the open approaches.

Are We Paying a High Price for Surgical Sympathectomy? A Systematic Literature Review of Late Complications

The purpose of this article was to systematically review the literature in order to assess (1) the current indications for surgical sympathectomy and (2) the incidence of late complications collectively and per indication. All types of upper or lower limb surgical sympathectomies are included. An extensive search strategy looked for controlled trials and observational studies or case series with an english abstract. Out of 1,024 abstracts from MEDLINE and 221 from EMBASE, 135 articles reporting on 22,458 patients and 42,061 procedures (up to april 1998) fulfilled the inclusion criteria. Weighted means were used to control for heterogeneity of data. No controlled trials were found. The main indication was primary hyperhidrosis in 84.3% of the patients. Compensatory hyperhidrosis occurred in 52.3%, gustatory sweating in 32.3%, phantom sweating in 38.6%, and horner's syndrome in 2.4% of patients, respectively, with cervicodorsal sympathectomy, more often after open approach. Neuropathic complications (after cervicodorsal and lumbar sympathectomy) occurred in 11.9% of all patients. Compensatory hyperhidrosis occurred 3 times more often if the indication was palmar hyperhidrosis instead of neuropathic pain (52.3% versus 18.2%), whereas neuropathic complications occurred 3 times more often if the treatment was for neuropathic pain instead of palmar hyperhidrosis (25.2% versus 9.8%). Surgical sympathectomy, irrespective of approach, is accompanied by several potentially disabling complications. Detailed informed consent is recommended when surgical sympathectomy is contemplated.

Thoracoscopic cervicodorsal sympathectomy with diathermy

This study reports our experience of using thoracoscopic cervicodorsal sympathectomy with diathermy. From December 1994 to September 1998, we performed 53 thoracoscopic sympathectomies in 35 patients. There were 15 men and 20 women, ages 18 to 61 years. Ten surgeries were performed on the right side, 7 were the left, and 18 were bilateral. Indications for surgery were causalgia/reflex sympathetic dystrophy in 8 patients, Raynaud's/vasculitis in 6, intractable Raynaud's disease in 4, and hyperhydrosis in 17 (bilateral procedure). Operating time ranged from 10 to 50 min for unilateral procedures and from 45 to 80 min for bilateral procedures. Patients stayed in the hospital 1 to 4 days. From favorable immediate and follow-up results we conclude that thoracoscopic cervicodorsal sympathectomy using diathermy is feasible, safe, and effective.

Endoscopic transthoracic dorsal sympathectomy for the treatment of upper extremity hyperhidrosis: a new minimally invasive approach

Palmar and axillary hyperhidrosis are best treated surgically by endoscopic transthoracic upper dorsal sympathectomy. At present, this methodology relies on (at least) double trocar insertion (per side), carbon dioxide insufflation, or both. We present a new minimally invasive endoscopic transthoracic technique, performed by a single-entry specifically modified thoracoscope and without the need for carbon dioxide insufflation, with the aim to reduce the drawbacks associated with the above-mentioned, currently adopted endoscopic technique. In our opinion, this "single-entry" technique, compared with the other reported approaches, should theoretically minimize any damage to the intercostal neurovascular bundle, while avoiding the complications related to carbon dioxide insufflation.

Simpatectomia cervicotoracica por videotoracoscopia: experiência inicial

O objetivo do presente trabalho é avaliar os resultados iniciais obtidos com a simpatectomia cervicotorácica videotoracoscópica. De outubro de 1995 a outubro de 1997 foram realizados 24 procedimentos em 14 pacientes: dez homens e quatro mulheres, com idades que variaram de 16 a 56 anos, média de 30 anos. Indicações para a operação foram: hiperidrose palmar em dez pacientes, isquemia de mão em três e causalgia em um. Nos casos de hiperidrose, a ressecção da cadeia simpática incluiu T2 e T3. Nos portadores de isquemia e causalgia também o gânglio estrelado foi ressecado. Vinte e três das 24 extremidades mostraram excelente resposta imediata à simpatectomia. Somente uma extremidade de paciente com hiperidrose permaneceu inalterada devido a procedimento incompleto, tendo sido desnervada pela mesma técnica em reoperação posterior, com bom resultado. Pneumotórax residual pós-operatório ocorreu em uma paciente com resolução espontânea. Treze pacientes tiveram seguimento que variou de dois a 18 meses, com média de 11 meses. Não houve mortalidade nessa série, e a principal complicação tardia observada nos pacientes operados por hiperidrose foi a hiperidrose compensatória, que ocorreu, em grau variado, nos nove pacientes com seguimento, sendo que em 30% deles esta manifestação foi significativa. Concluímos tratar-se de procedimento simples, seguro, eficiente e de melhor aceitação por parte dos pacientes do que a operação convencional.

Successful treatment of facial blushing by endoscopic transthoracic sympathicotomy

Facial blushing is one of the cardinal symptoms of social phobia and has a strong negative impact on the quality of life. Traditional therapeutic options are psychotherapy and pharmacological treatment. The results of these treatments on facial blushing are poorly documented. To investigate whether endoscopic bilateral transection of the upper thoracic sympathetic chain is efficient in the treatment of facial blushing, 244 consecutive patients were treated with bilateral endoscopic transthoracic sympathicotomy (ETS). The results were evaluated by questionnaire and symptoms assessed with visual analogue scales (0-10). There was no mortality nor conversion to open surgery. No Horner's syndrome occurred. Two patients with postoperative pneumothorax were treated with intercostal drainage and one small pulmonary embolus was detected. The questionnaire was answered by 219 patients (90%) a mean (+/- SEM) of 8 months (+/- 9 days) after surgery. Facial blushing (mean +/- SEM) was reduced from 8.7 +/- 0.1 to 2.2 +/- 0.2, P < 0.0001, by the operation. Heart palpitations in stressful situations were also reduced (3.7 +/- 0.3 to 1.3 +/- 0.1, P < 0.0001). The quality of life was substantially improved. The main side-effect was redistribution of sweating from the upper to the lower part of the body. Increased sweating of the trunk occurred in 75% of the patients. Overall, 85% of the patients were satisfied with the result and 15% were to some degree dissatisfied, mainly due to insufficient effect, but only four patients (2%) regretted the operation. As this is an open study, the results must be viewed with caution. ETS, however, appears to be an efficient, safe and minimally invasive surgical method for the treatment of facial blushing.

Altered response in cutaneous sympathetic outflow to mental and thermal stimuli in primary palmoplantar hyperhidrosis

Skin sympathetic nerve activities (SSNAs) were recorded simultaneously from the tibial and peroneal nerves by microneurography at an ambient temperature of 25 degrees C in five subjects with primary palmoplantar hyperhidrosis. The resting of the tibial SSNA innervating the sole (glabrous skin) increased moderately (36.5 +/- 1.5 bursts/min), while mental arithmetic provoked marked responses (1,003.3 +/- 457.4% compared with the resting level) in the hyperhidrosis group compared with the control normohidrosis group (n = 5, 25.3 +/ 4.2 bursts/min and 142.2 +/- 58.4%, respectively). Differentiation of the tibial SSNA into sudomotor (innervating sweat glands) and vasoconstrictor (innervating presphincter of skin vessels) revealed that this SSNA enhancement was attributable to not only sudomotor but also vasoconstrictor components during mental arithmetic. In contrast, the responses in the peroneal SSNA (innervating the dorsum pedis, hairy skin) of the hyperhidrosis group were only slightly changed, exhibiting no significant difference from those in the normohidrosis group. Reflex bursts elicited by sound and electric stimulation were normal in amplitude and latency. When the ambient temperature was elevated to 30 degrees C, the tibial SSNAs became more enhanced than did the peroneal SSNAs. The tibial SSNA was markedly enhanced in the hyperhidrosis group (290.0 +/- 78.5%) compared with the normohidrosis group (78.3 +/- 25.4%). We conclude that the excessive responses in SSNA to the plantar glabrous skin to both mental and thermal stimuli may be responsible for the profuse sweating in subjects with primary palmoplantar hyperhidrosis.

Angina pectoris treated by thoracoscopic sympathecotomy

Open surgical sympathectomy has previously been shown effective in relieving severe angina pectoris. The method was hampered by high morbidity and mortality. The authors have developed a minimally invasive technique of dividing only the sympathetic chain endoscopically and obtained good results with no serious complications in patients operated on for severe palmar hyperhidrosis. This method was used in 43 patients with severe angina pectoris who were not eligible for coronary artery bypass grafting or percutaneous transluminal coronary angioplasty. There was no mortality or any severe complications. Some 19 patients became symptom-free while 22 were improved and two unchanged after surgery. The frequency of anginal attacks was significantly reduced, as was the consumption of nitroglycerine tablets. The maximum exercise capacity was significantly increased and ST-segment depression reduced.

Abolition of sympathetic skin responses following endoscopic thoracic sympathectomy

The recording of sympathetic skin responses (SSRs) is a simple, electrophysiological method to assess sympathetic nerve function. Within the last 10 years, SSRs have mainly been applied to delineate peripheral and central nervous system diseases, although the sympathetic nature of these responses was not fully documented, e.g., by a study of sympathectomy. We therefore recorded SSRs before and after 30 cases of endoscopic thoracic sympathectomy. The main indication was palmar hyperhidrosis, in which we found two types of SSR abnormalities. Most patients exhibited normal SSR waveforms but with increased amplitudes. The other patients exhibited abnormal SSRs which did not occur as single responses but as several consecutive waves. Thoracic sympathectomy always led to significant clinical improvement and to the abolition of ipsilateral palmar SSRs, demonstrating the sympathetic origin of these responses. We suggest that the assessment of sympathetic nerve activity by SSR recordings may be useful in sympathectomy.

Endoscopic transthoracic sympathectomy: an efficient and safe method for the treatment of hyperhidrosis

BACKGROUND

Hyperhidrosis of the palms, axillae, and face has a strong negative impact on the quality of life for many persons. Existing nonsurgical therapeutic options are far from ideal. Definitive cure can be obtained by upper thoracic sympathectomy. The traditional open surgical technique is a major procedure; few patients and doctors have found that risk-benefit considerations favor surgery. Endoscopic minimal invasive surgical techniques are now available.

OBJECTIVE

We investigated whether endoscopic ablation of the upper thoracic sympathetic chain is efficient and safe in the treatment of hyperhidrosis.

METHODS

We treated 850 patients with bilateral endoscopic transthoracic sympathectomy.

RESULTS

There was no mortality or life-threatening complication. Nine patients (1%) required intercostal drainage because of hemothorax or pneumothorax. Treatment failure occurred in 18 cases (2%) and symptoms recurred in 17 patients (2%). At the end of follow-up (median, 31 months) 98% of the patients reported satisfactory results.

CONCLUSION

Endoscopic transthoracic sympathectomy is an efficient, safe, and minimally invasive surgical method for the treatment of palmar, axillary, and facial hyperhidrosis.

Thoracoscopic cervicodorsal sympathectomy: preliminary results

PURPOSE

The purpose of this study was to determine the feasibility, safety, and efficacy of thoracoscopic cervicodorsal sympathectomy.

METHODS

From March 1990 to December 1993, we performed 21 thoracoscopic sympathectomies in 19 patients. There were 13 women and six men; age 17 to 64 years, mean 37 years. Thirteen procedures were performed on the left side and eight on the right. Indications for surgery were causalgia/reflex sympathetic dystrophy in nine patients, Raynaud's/vasculitis in six, hyperhidrosis in five, and medically refractory cardiac arrhythmia in one.

RESULTS

The T1-4 sympathetic ganglia were readily identified, dissected free, and resected thoracoscopically in 19 cases, and the T3-7 ganglia were resected with thoracoscopy in one case. One case required conversion to an open thoracotomy because of dense scar from a previous first rib resection, which obscured the anatomy. Histologic confirmation of ganglia were obtained in all 21 cases. Operative duration ranged from 1.0 to 3.5 hours. Estimated blood loss was 5 to 300 cc, mean 42 cc, median 10 cc. No patient required transfusion. All 21 patients had an excellent immediate sympathectomy response. Transient Horner's syndrome developed in two patients. Postoperative residual pneumothorax (< 10%) occurred in three cases and resolved spontaneously without further treatment. In one patient pleural effusion and pneumothorax developed, which were treated with the reinsertion of the chest tube. Postoperative pain was well controlled with oral analgesics. Hospital stay was 1 to 4 days, mean 2 days, median 1 day. Follow-up at 1 to 42 months, mean 11 months, median 6 months, showed continued evidence of sympathectomy effect in all patients, except one who died of her underlying disease 1 month after operation.

CONCLUSIONS

We conclude that thoracoscopic sympathectomy is feasible, safe, and effective. Further studies are indicated to confirm its long-term benefits and to determine optimal thoracoscopic techniques.