Thoracoscopic Sympathicotomy vs Sympathectomy in Primary Hyperhidrosis

Clinical Outcomes of Uniportal Versus Multiportal Endoscopic Thoracic Sympathectomy in Patients With Severe Palmar and Axillary Hyperhidrosis

Objective: Palmar and axillary hyperhidrosis is caused by overstimulation of the sympathetic nervous system that control the sweat glands. This study compares the clinical consequences of uniportal and multiportal thoracic endoscopic thoracic sympathectomy (ETS), in cases of severe palmar and axillary hyperhidrosis. Methods: In this retrospective study, forty-one patients who were diagnosed as severe palmar and axillary primary hyperhidrosis were analyzed. These underwent multiportal ETS between 2015 and 2020 at our thoracic surgery clinic. They were divided into two groups, 24 as uniportal (58.5%) and 17 as multiportal (41.5%). They were compared in terms of the length of hospital stay, the initial complications and possible recurrences after three months. Descriptive statistics were used to evaluate stratified and continuous variables. Results: There was no significant difference in moderate pain between the two groups. There was a significant difference between the two groups in terms of 3 days or more hospitalization. There were no significant difference related to the rate of complications such as ptosis, Horner syndrome, increased duration of surgery and recurrence rate of hyperhidrosis 3 months after surgery. Some mild to moderate side effects disappeared spontaneously at 6-month follow-up. Conclusion: The results showed that uniportal and multiportal endoscopic thoracoscopic sympathectomy (EST) are very effective, safe and minimally invasive methods for the treatment of palmar and axillary hyperhidrosis. Compared to the multiportal approach, uniportal EST causes less postoperative pain and less surgical duration.

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.

Selective T3-T4 sympathicotomy versus gray ramicotomy on outcome and quality of life in hyperhidrosis patients: a randomized clinical trial

Compensatory hyperhidrosis is the leading cause of patients' dissatisfaction after thoracic sympathicotomy. The study aimed to reduce compensatory hyperhidrosis to increase patients’ satisfaction. A prospective randomized study on palmar hyperhidrosis, May 2016–September 2019. Twenty-one patients T₃–T₄ sympathicotomy and 21 T₃–T₄ gray ramicotomy. Data prospectively collected. Analysis at study's end. Focus on the sweating, temperature, quality of life baseline and postoperatively, compensatory hyperhidrosis, hand dryness, patients' satisfaction, and if they would undergo the procedure again and recommend it. No baseline differences between groups. Hyperhidrosis was controlled postoperatively in all patients. No mortality, serious complications, or recurrences. Sympathicotomy worse postoperative quality of life (49.05 (SD: 15.66, IR: 35.50–63.00) versus ramicotomy 24.30 (SD: 6.02, IR: 19.75–27.25). After ramicotomy, some residual sweating on the face, hands, and axillae. Compensatory sweating worse with sympathicotomy. Satisfaction higher with ramicotomy. Better results with ramicotomy than sympathicotomy regarding hand dryness, how many times a day the patients had to shower or change clothes, intention to undergo the procedure again or recommend it to somebody else, and how bothersome compensatory hyperhidrosis was. T₃–T₄ gray ramicotomy had better results than T₃–T₄ sympathicotomy, with less compensatory sweating and higher patients' satisfaction.

Rib-oriented Thoracoscopic Sympathetic Surgery for Hyperhidrosis: Prospective Long-term Results and Quality of Life

BACKGROUND

The optimal thoracoscopic sympathetic surgery for primary palmar and/or axillary hyperhidrosis (PPAH) is still unclear because of lack of uniform technique and qualitative/quantitative scales for definition of results. The aims of this study were to compare long-term outcomes based on the surgical technique and the level of sympathetic trunk interruption by clipping and to assess postoperative compensatory sweating (CS), patients' satisfaction, and quality of life (QoL).

MATERIALS AND METHODS

Between September 2009 and April 2016, 94 patients who underwent 2-stage bilateral thoracoscopic rib-oriented (R) sympathetic clipping were prospectively followed up through the administration of standardized preoperative and postoperative questionnaires.Thirty-four (36.2%) patients underwent single-port transaxillary access instead of the standard two 5-mm incisions. The level of sympathetic clipping for PPAH was R3+4(top and bottom); in patients who complained associated facial or plantar hyperhidrosis R2-bottom and R5-top were clipped, respectively. Seventy-five patients completed bilateral surgery.

RESULTS

There were no significant differences between single-port and biportal video-assisted thoracoscopic surgery in terms of operative times and postoperative results. At a mean follow-up of 72 (SD: 26) months, CS was reported in 42 (56%) patients, severe only in 6 (8%). It was higher in the case of R2-bottom clipping (P=0.03). Thirty-one of 60 (51.6%) patients who had a plantar hyperhidrosis declared an improvement of feet sweating after surgery. Postoperative satisfaction was excellent (86.11% on a 0 to 100 scale) and 95.4% of patients declared an improvement in QoL, which was statistically significant in all evaluated parameters. These results were not related to the level of clipping.

CONCLUSION

Thoracoscopic R3 to R4 clipping appears to be a safe and effective treatment for PPAH. Although postoperative CS was common and higher after R2-bottom clipping, this did not seem to affect patients' satisfaction and improvement in QoL.

The Rate of Compensatory Sweating and Clinical Outcomes of Selective Thoracoscopic Sympathectomy (Ramicotomy) in Patients with Primary Palmar Hyperhidrosis

Background: Primary hyperhidrosis is a sympathetic disorder characterized by prolonged and uncontrollable sweating. It is associated with emotional stress or psychological causes that preferably affects the axillae, palms, feet, and face. Video-assisted thoracoscopic sympathetic surgery is currently a globally recognized treatment for primary palmar hyperhidrosis (PH). However, compensatory sweating (CS) is the most prominent long-term adverse effect of thoracoscopic sympathectomy. Objectives: Here, we aim to perform selective sympathetic ramicotomy for primary palmar hyperhidrosis patients and evaluate the clinical outcomes of satisfaction, as well as the effect on the frequency, location, and severity of compensatory sweating. Methods: In this single-arm trial study, 24 sympathectomies were carried out on 12 patients with primary palmar hyperhidrosis who were candidates for bilateral thoracoscopic selective sympathectomy (ramicotomy) at Imam Khomeini Hospital. The patients’ demographic information was interviewed and followed up using telephone questionnaires in the health center one week after surgery. Then, the rates of compensatory sweating, satisfaction, and failure or recurrence were retrospectively analyzed. Results: No significant differences were observed between age, gender, weight, BMI, and compensatory sweating rates. Notwithstanding, there was a statistically significant difference in the severity of compensatory sweating with patients’ height (P = 0.016). Compensatory sweating occurred in 66.7% of the patients; 50% of the patients were mild, 16.7% of the patients were moderate, and there was no intolerable compensatory sweating or recurrence. The most incidence of compensatory sweating was on the lower back. The rate of satisfaction was 94.5 ± 7.8%. Conclusions: Selective thoracoscopic sympathectomy (ramicotomy) is an effective surgical procedure with a very high level of precision and satisfaction. This technique hence should be considered the method of choice for the treatment of primary palmar hyperhidrosis.

Selective block of grey communicantes in upper thoracic sympathectomy. A feasibility study on human cadaveric specimens

Background: Sympathetic chain interruption is the gold standard treatment for essential hyperhidrosis. Postoperative compensatory hyperhidrosis, the main reason for patients' dissatisfaction, is reduced by selectively lesioning white and grey rami communicantes (ramicotomy).Objective: To develop an endoscopic surgical technique that interrupts only T₃ and T₄ grey rami communicantes to minimize compensatory hyperhidrosis.Material and Methods: T₃ and T₄ grey rami communicantes ramicotomy in fifteen cold-preserved cadavers through a uniportal axillary endoscopic approach. The sympathetic chain, its ganglia, and white rami communicantes were left intact. On opening the chest, the sympathetic chain, rami communicantes and ganglia were dissected, photographed, measured and excised for histological examination.Results: Dissecting the grey rami communicantes is feasible as they consistently lie between the intercostal nerve and the homonymous sympathetic ganglion. At some levels, Kuntz nerves, as well as more than one grey ramus communicans, can be found. White rami communicantes are more medial, therefore damaging them can be avoided. Intercostal veins can be obstructive, but these can be controlled via coagulation or clipping if necessary.Conclusion: Uniportal endoscopic selective excision of the T₃ and T₄ grey rami communicantes is feasible without damaging the white rami communicantes, the sympathetic chain or its ganglia. Clipping the grey rami communicantes is technically possible but not reliable due to their thin diameter. This study confirms that T₃ and T₄ grey rami sympathetic block is technically feasible. Its application might reduce compensatory hyperhidrosis, but clinical studies are needed.

Compensatory hyperhidrosis after different surgeries at the same sympathetic levels: a meta-analysis

Background

Different techniques of video-assisted thoracoscopic sympathetic surgery have become the radical treatments for palmar and axillary hyperhidrosis (AH). However, there is no consensus over which technique can make a minimal incidence of compensatory hyperhidrosis (CH). This study was designed to compare the incidence of CH after different techniques at the same sympathetic levels in the treatment of upper limb and facial hyperhidrosis (FH).

Methods

The databases of PubMed, Web of Science, ScienceDirect, Ovid Medline, Embase, and Cochrane Library were searched to identify studies comparing different surgical techniques at the same sympathetic levels for upper limb and FH. The data was analyzed by Revman 5.3 software.

Results

A total of ten studies involving 896 patients were included, of whom 149 underwent sympathectomy, 435 underwent sympathicotomy, and 312 under endoscopic sympathetic clip (ESC). Meta-analysis showed that the difference of incidence of CH and patients' satisfaction was not significant between sympathectomy and sympathicotomy (P=0.05, 0.19, respectively). But, the incidence of CH is significant lower after ESC than after sympathicotomy (OR: 1.58, 95% CI: 1.04-2.38, P=0.03). However, the incidence of moderate/severe CH between these two groups is not significant different (OR: 1.49, 95% CI: 0.93-2.39, P=0.10).

Conclusions

If only CH and the same sympathetic levels concerned, sympathectomy and sympathicotomy is equal for upper limb hyperhidrosis and FH. And, ESC should be recommended for a lower incidence of CH, comparing with sympathicotomy.

Early results of new endoscopic thoracic sympathectomy for craniofacial hyperhidrosis

Background

Endoscopic thoracic sympathectomy (ETS) has been considered as a definitive treatment for hyperhidrosis. However, despite its well-established success rate, surgical treatment for craniofacial hyperhidrosis (CFH) is rarely performed due to the possibility of fatal complications and compensatory sweating. The aim of this study was to evaluate the safety and efficacy of our newly developed method of ETS for CFH, based on early results.

Methods

Between June 2016 and October 2017, a total of 70 patients underwent ETS with our new technique for CFH. All patients were placed under double-lumen intubation anesthesia with CO2 gas installation. We utilized two ports, one for 2-mm endoscope and another for 3-mm instrument. Our technique involved R2 and R4-R7 sympathectomy with R4-R7 truncal ablation.

Results

There were 55 males and 15 females, with a mean age of 48 years (range, 22-75 years). The median operation time was 38 minutes (range, 28-75 minutes). There was no operative mortality and morbidity. During the short follow-up period (average 7 months; range, 1-17 months), symptoms were improved in all patients and compensatory hyperhidrosis was observed 68 patients: mild in 50 patients (71.4%), moderate in 13 patients (18.6%), and severe in 5 patients (7.1%).

Conclusions

In select patients, our technique of ETS appears to be a safe and effective treatment method for treating CFH. However, a study with long-term follow-up is still necessary to confirm our findings.

Thoracoscopic sympathicotomy in the treatment of palmar hyperhidrosis

Background

Primary hyperhidrosis interferes with social activities and requires an effective and safe treatment. We aimed to compare the therapeutic outcomes of unilateral single-port sympathicotomy and open surgery.

Methods

Forty patients with primary palmar hyperhidrosis underwent sympathicotomy; 20 had open surgery, and 20 had video-assisted thoracic surgery. Complete resection of the T1 to T4 ganglia was performed by open surgery, and cutting and cauterization of the sympathetic chain between the T2 and T3 ganglia in the dominant hand was undertaken using video-assisted thoracic surgery. The patients were followed up at 1, 3, 6, and 12 months after surgery.

Results

The mean operative times were 39.6 ± 1.46 and 79.8 ± 1.53 min in the video-assisted thoracic surgery and open surgery group, respectively. The mean hospitalization was 2.2 ± 0.41 days after video-assisted thoracic surgery and 3.3 ± 0.47 days after open surgery. Complications included delayed hemothorax, compensatory hyperhidrosis, and wound infection. The mean blood loss during surgery and time to return to work were significantly less in the video-assisted thoracic surgery group. Excessive sweating was completely alleviated in the dominant hand in all patients, and in the opposite hand in 60% and 65% of the video-assisted thoracic surgery and open surgery group, respectively.

Conclusion

Single-port sympathicotomy between the T2 and T3 ganglia ipsilateral to the dominant hand is a safe, minimally invasive, and effective treatment for primary palmar hyperhidrosis. Alleviation of excessive sweating in the opposite hand can also be achieved in a large proportion of these patients.

Comparisons of the clinical outcomes of thoracoscopic sympathetic surgery for palmar hyperhidrosis: R4 sympathicotomy versus R4 sympathetic clipping versus R3 sympathetic clipping

BACKGROUND

Thoracoscopic sympathetic surgery is regarded as a definitive treatment for palmar hyperhidrosis. However, the optimal surgical strategy remains unclear. The aim of this study was to compare outcomes based on the level and type of sympathetic disconnection in patients with palmar hyperhidrosis.

METHODS

From January 2009 to December 2014, 101 patients with palmar hyperhidrosis underwent thoracoscopic sympathetic surgery at Gangnam Severance Hospital. Complete follow-up information was obtained from 59 patients. We retrospectively analyzed the results of operation, degree of palmar sweating (%), grade of compensatory sweating (none, mild, moderate, severe, very severe), grade of satisfaction (very satisfied, satisfied, moderate, dissatisfied, very dissatisfied), and recurrence/failure.

RESULTS

R4 sympathicotomy, R4 sympathetic clipping, and R3 sympathetic clipping were performed in 16, 20, and 23 patients, respectively. The mean degree of palmar sweating after sympathetic surgery was not significantly different between these three groups (17.50% vs. 27.00% vs. 29.78%; P=0.38). The rate of life-bothering compensatory sweating was lower in the R4 sympathicotomy group compared with those of other two groups (0% vs. 25%, 47.8%; P=0.09). The rate of very satisfied to moderate grades of satisfaction were lower in the R3 sympathetic clipping group compared with those of other two groups (93.8%, 100% vs. 73.9%; P=0.07). The rate of recurrence/failure rates were lower in the R4 sympathicotomy group compared with those of other two groups (12.50% vs. 35.00%, 34.8%; P=0.25). Sympathetic surgery at the R3 level was the only significant risk factor for patient dissatisfaction (odd ratio =12.353, 95% confidence interval =1.376-110.914; P=0.025).

CONCLUSIONS

Our data support that R4 sympathicotomy had lower grades of compensatory sweating, higher grades of satisfaction, and lower rates of recurrence/failure. We therefore consider R4 sympathicotomy as an optimal surgical treatment for palmar hyperhidrosis.