Embryonic NOTES thoracic sympathectomy for palmar hyperhidrosis: results of a novel technique and comparison with the conventional VATS procedure

Hyperhidrosis: A targeted literature review of the disease burden

Hyperhidrosis is a chronic skin condition characterized by excessive sweating. It poses a burden on affected people, reducing their quality of life and productivity. We undertook a targeted literature review (TLR) to gather current evidence on the epidemiology as well as the human and economic burden posed on patients with hyperhidrosis. Searches were performed in Medline database (access via OVID interface) and ICHUSHI database. Articles published between January 2000 and September 2020 that analyzed at least 50 patients were included. Sixty-four publications were identified and 38 publications covering a unique domain were selected to inform this TLR. The incidence of hyperhidrosis ranged from 0.13% in the UK to 0.28% in the USA, with a higher rate in females. The prevalence of hyperhidrosis varied from 2.8%-4.8% in the US general population to 18.40% in Chinese inpatients, while the prevalence of axillary hyperhidrosis varied from 1.4% in the US general population to 5.75% in Japanese employees/students. Due to excessive sweating, hyperhidrosis was reported to be a moderate-to-extreme limitation at work for the US patients, with 33.5% feeling unhappy. Patients' satisfaction was high post-treatment. Considerable costs were related to the treatment with botulinum toxin and surgery. Hospital stays for surgery lasted from 10 h to 3 days. The percentage of patients who sought a medical consultation varied from 6.3% for Japanese patients with primary focal hyperhidrosis to 51% for the US general population with any type of hyperhidrosis. There is limited evidence of the hyperhidrosis burden, particularly among Japanese patients; however, the burden was high and limited patients' daily functioning. Future actions should include implementation of educational programs to raise awareness of the condition, conduct of larger studies, and generation of more evidence. Understanding the nature of hyperhidrosis and the burden it poses is of utmost importance.

Chinese expert consensus on the surgical treatment of primary palmar hyperhidrosis (2021 version)

Primary palmar hyperhidrosis (PPH) is a pathologic condition of excessive sweating on hands that has adverse impacts on patients’ social activity, professional life, and psychological state. Endoscopic thoracic sympathicotomy (ETS) is by far the treatment choice for PPH with the most stable and durable curative effects, but special attention should be given to the side effects of the surgery, especially compensatory hyperhidrosis (CH). This consensus is the second version of the Chinese Expert Consensus on the Surgical Treatment of PPH by the China Expert Committee on Palmar Hyperhidrosis (CECPH), which was published 10 years ago. This consensus emphasizes the need for special attention and careful assessment of the patients’ feelings, as well as their emotional and mental state, and emphasizes that distress due to palmar sweating and the desire for treatment are prerequisites for diagnosis. It also provides a more nuanced delineation of CH and reviews all new attempts to prevent and treat this side effect. New evidence of the epidemiology, pathogenesis of PPH, and indications for surgery were also assessed or recommended.

Quality of life after thoracic sympathectomy for palmar hyperhidrosis: a meta-analysis

OBJECTIVE

Palmar hyperhidrosis affects 0.6-10% of the general population, having an important impact in patients' quality of life. The definitive treatment for palmar hyperhidrosis is thoracic sympathectomy. The purpose of this study is to evaluate the quality of life after thoracic sympathectomy for palmar hyperhidrosis.

METHODS

The interest studies were searched in six comprehensive databases. The quality of the studies was assessed using the risk of bias tool recommended by the Cochrane system evaluation manual. Meta-analysis was performed with RevMan version 5.3. The outcome of interest was quality of life. The subgroup analysis and sensitive analysis were performed.

RESULTS

Nine trials, including 895 patients, with accessible data comparing preoperative quality of life score with postoperative quality-of-life score were used for data analysis. Compared with preoperative quality-of-life score, application of thoracic sympathectomy improved the postoperative quality of life of palmar hyperhidrosis patients (MD = 57.81, 95% CI 53.33-62.30). Subgroup analysis of the different thoracic sympathectomy segment showed that there was no significant difference in the results obtained when operated with single segment or multiple segments (single segment: MD = 61.16, 95% CI [56.10, 66.22], multiple segments: MD = 52.14, 95% CI [48.39, 55.88]).

CONCLUSION

The meta-analysis provided evidence of the improved quality of life after thoracic sympathectomy for palmar hyperhidrosis.

Optimal targeting of sympathetic chain levels for treatment of palmar hyperhidrosis: an updated systematic review

BACKGROUND

Palmar hyperhidrosis involves excessive sweating of the palms, with no known etiology. Endoscopic thoracic sympathectomy (ETS) is a safe and effective treatment for palmar hyperhidrosis, but compensatory hyperhidrosis is a common complication after ETS, leading to reduced patient satisfaction and postoperative quality of life. However, the appropriate level of the sympathetic chain to target with ETS to achieve maximum efficacy and reduce the risk of compensatory hyperhidrosis (CH) is controversial. In this systemic review, we investigated the appropriate level of sympathectomy for palmar hyperhidrosis.

METHODS

PRISMA guidelines were implemented to complete a systematic review. We performed a computerized systematic literature search using PubMed and EMBASE from January 1990 to July 2016. We chose the Cochrane Collaboration's tool and the methodological index for non-randomized studies tool for examining study bias.

RESULTS

A total of 4075 citations were identified, of which 91 were eligible for inclusion, including 68 observational studies and 23 comparative trials. In observational studies, sympathectomies showed similar efficacies for curing PH at different levels. However, T2-free groups (i.e., at levels T3, T4, or T3-T4 combined) could render a lower risk of Horner's syndrome (0 vs. 1.21 ± 0.49%, p = 0.036) and CH (28.75 ± 7.25 vs. 57.46 ± 3.86, p = 0.002) compared with T2 involved. In comparative trials, there were 12 studies describing the comparison between T2-free ETS and T2 involved, and 9 of 12 (75%) showed T2-free ETS could reduce the incidence of CH. Overall, lowering the level and limiting the extent of sympathectomy could reduce the incidence of complications.

CONCLUSIONS

Cumulative data from more than 13,000 patients suggest that ETS is a safe, effective, and reproducible procedure with a high degree of patient satisfaction. Currently available evidence suggests that T2-free ETS may reduce the incidence of compensatory hyperhidrosis without compromising success rates and safety.

Comparison of acute phase protein and hemodynamic variables in dogs undergoing video-assisted thoracoscopic vs. open pneumonectomy

It has been demonstrated that video-assisted thoracoscopic surgery (VATS) is feasible and safe in humans and animal models. The aim of the present study was to compare the surgical outcome using VATS with that of the standard transthoracic approach for pneumonectomy in dogs, to determine the acute-phase reaction in VATS pneumonectomy, and to analyze the difference between VATS and the standard transthoracic approach. A total of 14 dogs were divided into two groups (n=7); one group underwent VATS and the other group underwent a transthoracic pneumonectomy. Pre-, intra- and post-operative physiologic parameters were monitored, in addition to the blood cell count and serum acute-phase protein (APP) concentrations. The APP and hemodynamic changes between the two approaches were analyzed. Mean surgical time in the VATS group (176.7 min) was significantly longer compared with the open group (132.4 min). All APP concentrations were significantly increased at day 1 postoperation and gradually decreased to preoperative concentrations. The serum concentration of C-reactive protein on day 3 and the white blood cell count on day 1 were significantly higher following surgery in the open group compared with the VATS group (P<0.05). No differences were observed in the physiological parameters between the two groups. Although VATS took longer, animals experienced smaller incision and less stress. Therefore, the VATS approach was satisfactory for total pneumonectomy.

Technological innovation in video-assisted thoracic surgery

The popularity of video-assisted thoracic surgery (VATS) which increased worldwide due to the recent innovations in thoracic surgical technics, equipment, electronic devices that carry light and vision and high definition monitors. Uniportal VATS (UVATS) is disseminated widely, creating a drive to develop new techniques and instruments, including new graspers and special staplers with more angulation capacities. During the history of VATS, the classical 10 mm 0° or 30° rigid rod lens system, has been replaced by new thoracoscopes providing a variable angle technology and allowing 0° and 120° range of vision. Besides, the tip of these novel thoracoscopes can be positioned away from the operating side minimize fencing with other thoracoscopic instruments. The curved-tip stapler technology, and better designed endostaplers helped better dissection, precision of control, more secure staple lines. UVATS also contributed to the development of embryonic natural orifice transluminal endoscopic surgery. Three-dimensional VATS systems facilitated faster and more accurate grasping, suturing, and dissection of the tissues by restoring natural 3D vision and the perception of depth. Another innovation in VATS is the energy-based coagulative and tissue fusion technology which may be an alternative to endostaplers.

Management of hyperhidrosis

Primary hyperhidrosis (HH), a condition of sweating in excess of thermoregulatory requirements, affects nearly 3% of the US population and carries significant emotional and psychosocial implications. Unlike secondary HH, primary HH is not associated with an identifiable underlying pathology. Our limited understanding of the precise pathophysiologic mechanism for HH makes its treatment particularly frustrating. However, a wide array of interventions for the treatment of HH have been implemented throughout the world. Herein, we discuss the most extensively studied therapeutic options for primary HH, including systemic oxybutynin, botulinum toxin injections, skin excision, liposuction–curettage, and sympathotomy/sympathectomy. We conclude with a discussion of possible future therapies for HH, including the applications of laser, microwave, and ultrasound technologies.

Single-port thoracic surgery: a new direction

Single-port video-assisted thoracic surgery (VATS) has slowly established itself as an alternate surgical approach for the treatment of an increasingly wide range of thoracic conditions. The potential benefits of fewer surgical incisions, better cosmesis, and less postoperative pain and paraesthesia have led to the technique’s popularity worldwide. The limited single small incision through which the surgeon has to operate poses challenges that are slowly being addressed by improvements in instrument design. Of note, instruments and video-camera systems that are narrower and angulated have made single-port VATS major lung resection easier to perform and learn. In the future, we may see the development of subcostal or embryonic natural orifice translumenal endoscopic surgery access, evolution in anaesthesia strategies, and cross-discipline imaging-assisted lesion localization for single-port VATS procedures.

Feasibility of transumbilical anatomic pulmonary lobectomy in a canine model

PURPOSE

Transthoracic thoracoscopic lobectomy is the preferred method of surgical treatment for early lung cancer. Current methods require a transthoracic approach and are associated with chronic postoperative pain in up to 25% of patients. Single-port transumbilical uniport surgery may offer advantages over multiport surgery with less postoperative pain and better cosmetic results. The aim of this study was to evaluate the feasibility of a transumbilical anatomic lobectomy of the lung (TUAL) in a canine model.

METHODS

TUAL was performed in 12 beagle dogs using a 3-cm umbilical incision combined with a 2.5-cm diaphragmatic incision. Variables evaluated for surgical outcomes were operating time, operative complications, body rectal temperature, respiratory rate, white blood cell count, and arterial blood gases.

RESULTS

TUAL was successfully completed in ten animals. There were six bleeding complications related to surgery. In four animals, an avulsion of pulmonary vessel causes intraoperative bleeding, requiring simultaneous pulmonary artery and bronchus resections. In one animal, slipping of endoclip after vessel clipping caused perioperative bleeding. The other animal encountered bleeding complication during dissection of inferior pulmonary vein. Both animals required conventional thoracotomy to complete the surgery.

CONCLUSIONS

TUAL in the canine model is feasible but associated with significant morbidity. With further development and refinement of instruments, comparative studies between the novel transumbilical lobectomy and the current video-assisted transthoracic lobectomy will clarify the role of transumbilical lobectomy in thoracic surgery.