Thoracoscopic sympathectomy for axillary hyperhidrosis: the influence of T4

Safety of Radiofrequency Ablation of Thoracic T2 and T3 Sympathectomy in Palmar Hyperhidrosis: A Case Report

Introduction

Hyperhidrosis is the maladjustment of excess sweating in specific parts of the body. Radiofrequency (RF) therapy has been successfully used to treat hyperhidrosis with a success rate of 85% - 95% in patients refractory to sympathectomy. The main hypothesis was the association between reduced palmar hyperhidrosis and radiofrequency RF therapy. The RF therapy is a less invasive technique, including the utilization of electromagnetic energy that is deposited near the nerve tissue. The mechanism of action of continuous RF could be explained by the destruction of afferent nerve fibers on their way from a nociceptive focus to the central nervous system. Pulsed RF was invented to explore this possibility, with the sole purpose of finding a less destructive and equally effective technique for the application of RF to afferent pathways. Herein, we further evaluated whether the procedure was safe without any complications in routine follow-up in palmar hyperhidrosis.

Case Presentation

Herein, we report the case of a male patient with an age of 22 years undergoing thermal RF sympathectomy therapy of thoracic T2 and T3 sympathetic ganglia for the palmar hyperhidrosis of his right hand observed for 3 months. The patient developed a contraction of the flexor involving the small muscles of the right hand with severe pain and congestion 17 days after the procedure without any other complications. The contraction was relieved by a sonar-guided median nerve block at the wrist with two injections of 2 mL lidocaine 2% and 2 mL dexamethasone.

Conclusions

This study has been the first clinical case report complicated by the development of a contraction of the flexor muscles of the right hand with severe pain and congestion. The spasm was gradually relieved by sonar-guided median nerve injection at the level of the wrist and intended to assess the role of RF ablation with a success rate of 85% - 95% in palmar hyperhidrosis.

Results of a 10-year follow-up study of botulinum toxin A therapy for primary axillary hyperhidrosis in Australia

Primary hyperhidrosis has a prevalence of 3-5% in the United States. It is a psychosocially disabling condition leading to low self-esteem, chronic stress and depressive symptoms. Several medical and surgical treatments exist, including botulinum toxin A, which internationally, has been shown effectively and safely to treat this condition achieving high patient satisfaction. In Australia, botulinum toxin A has been available under the Medicare benefits scheme for axillary hyperhidrosis since 2013, but efficacy and treatment satisfaction had not been evaluated. We present the results of the first Australian study on efficacy and patient satisfaction with botulinum toxin A in primary axillary hyperhidrosis with evaluation of possible prognostic factors.

Regret in Surgical Decision Making: A Systematic Review of Patient and Physician Perspectives

OBJECTIVE

Regret is a powerful motivating factor in medical decision making among patients and surgeons. Regret can be particularly important for surgical decisions, which often carry significant risk and may have uncertain outcomes. We performed a systematic review of the literature focused on patient and physician regret in the surgical setting.

METHODS

A search of the English literature between 1986 and 2016 that examined patient and physician self-reported decisional regret was carried out using the MEDLINE/PubMed and Web of Science databases. Clinical studies performed in patients and physicians participating in elective surgical treatment were included.

RESULTS

Of 889 studies identified, 73 patient studies and 6 physician studies met inclusion criteria. Among the 73 patient studies, 57.5% examined patients with a cancer diagnosis, with breast (26.0%) and prostate (28.8%) cancers being most common. Interestingly, self-reported patient regret was relatively uncommon with an average prevalence across studies of 14.4%. Factors most often associated with regret included type of surgery, disease-specific quality of life, and shared decision making. Only 6 studies were identified that focused on physician regret; 2 pertained to surgical decision making. These studies primarily measured regret of omission and commission using hypothetical case scenarios and used the results to develop decision curve analysis tools.

CONCLUSION

Self-reported decisional regret was present in about 1 in 7 surgical patients. Factors associated with regret were both patient- and procedure related. While most studies focused on patient regret, little data exist on how physician regret affects shared decision making.

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.

Thoracic sympathectomy at the level of the fourth and fifth ribs for the treatment of axillary hyperhidrosis

OBJECTIVE

To describe the clinical results and the degree of satisfaction of patients submitted to thoracic sympathectomy at the level of the fourth and fifth ribs (R4-R5) for the treatment of axillary hyperhidrosis.

METHODS

We included 118 patients diagnosed with axillary hyperhidrosis and having undergone axillary sympathectomy at the R4-R5 level between March of 2003 and December of 2007 at the Paraná Federal University Hospital de Clínicas, located in the city of Curitiba, Brazil. All procedures were carried out by the same surgeon. Data regarding the resolution of axillary hyperhidrosis and the degree of patient satisfaction with the surgical outcome, as well as compensatory hyperhidrosis in the early and late postoperative periods (after 7 days and after 12 months, respectively), were collected.

RESULTS

Of the 118 patients evaluated, 99 (83.9%) and 81 (68.6%) showed complete resolution of the symptoms in the early and late postoperative periods, respectively. Compensatory hyperhidrosis occurred in 49 patients (41.5%) in the early postoperative period and in 77 (65.2%) in the late postoperative period. Of those 77, 55 (71.4%) categorized the compensatory hyperhidrosis as mild. In the early postoperative period, 110 patients (93.2%) were satisfied with the surgical results, and 104 (88.1%) remained so in the late postoperative period.

CONCLUSIONS

Sympathectomy at the R4-R5 level is efficient in the resolution of primary axillary hyperhidrosis. The degree of patient satisfaction with the long-term surgical results is high. Mild compensatory hyperhidrosis is the main side effect associated with this technique.

Comparison of ultrasonic scalpel to electrocautery in patients undergoing endoscopic thoracic sympathectomy

BACKGROUND

Sympathectomy is an effective treatment for hyperhidrosis. The ultrasonic scalpel and electrocautery have been used for the procedure, but the use of the ultrasonic scalpel has been promoted as superior to that of electrocautery. This study explored whether a reusable electrocautery probe was equally as effective and safe as the ultrasonic scalpel for sympathectomy.

METHODS

We retrospectively analyzed 140 consecutive patients. The ultrasonic scalpel (HDH 05, Ethicon Endo-Surgery, Cincinnati, OH) was used in 70 patients (group 1) and a reusable 5-mm cautery hook (Edlo, Canoas, Brazil) was used in 70 patients (group 2). End points were improvement in symptoms (% improvement score), length of stay, return to work, and complications. Data were analyzed using two-tailed t test and the chi(2) (p = 0.05 was significant). Data are mean +/- standard deviation.

RESULTS

Follow-up was 27.2 +/- 8.4 months. Groups were similar in demographics, disease site, and level of sympathectomy. There was no significant difference in improvement score by site. The feet had the least improvement score (36.5% +/- 32.3%), and the hands the highest improvement score (97.0% +/- 11.3%). Length of stay was similar, 11.4 +/- 5.9 (group 1) vs 10.1 +/- 5.4 hours (group 2). Return to work in group 1 was 4.8 +/- 2.7 vs 5.7 +/- 3.6 days (p = 0.09). Group 1 had 14 complications and group 2 had 7 (p = 0.16).

CONCLUSIONS

We could not demonstrate a clear advantage in the use of the ultrasonic scalpel.

[Therapeutic modalities in the treatment of palmar and axillary hyperhidrosis]

The authors summarize their therapeutic methods of palmar and axillary hyperhidrosis in this article. They discuss the characteristics, frequency of upper limb and patho-anatomical features of chronic sweating. Authors summarized their almost 40 years experience in treatment methods, technological improvements as well as they review recent knowledge and relevant literature. The open thoracotomic desympathization applied in the beginnings was gradually replaced by a minimally invasive VATS-sympathectomy (Video Assisted Thoracoscopic Surgery). The possibilities of conservative treatments, local excision methods will also be discussed, as well as the application and efficiency of Botox-treatments that are used in plastic surgery. The mean frequency of 0.1-1.0% described in scientific literature is indicative of a significant number of unresolved cases, which thus requires more efficient diagnostic and patient orientation practices. Based on their experiences, the most efficient treatment of upper limb hyperhidrosis is the thoracic sympathectomy (ramicotomy and the relevant T(2) -T(3) ganglia) according to Smithwick-procedure and modified by others. If necessary, one-stage bilateral VATS-surgery may be applied. Another effective conservative possibility is the Botox-therapy, which they had applied individually at the plastic surgery clinic. Significant complications or compensatory hyperhidrosis were not detected.

Transection of more than one sympathetic chain ganglion for hyperhidrosis increases the severity of compensatory hyperhidrosis and decreases patient satisfaction

Sympathectomy (ETS) is an effective treatment for hyperhidrosis (HH), but compensatory hyperhidrosis (CH) is a common side effect. We reviewed our experience with 200 patients. Two hundred patients were retrospectively analyzed. Patients completed a questionnaire regarding their postoperative symptoms [% improvement score (IS), CH score], and their level of dissatisfaction, which was assessed as a function of regretting the choice to undergo ETS. Significance set at P< or =0.05. There were 123 (61.5%) females. Mean age was 28.2+/-7.4. Follow-up (mo) was 20.9+/-12.1. One ganglion was transected in 112 (56%) patients (G1), and more than one in 88 (G2). Overall, 157 (78.5%) patients had CH, 88 (74.1%) patients in G1 and 74 (84.1%) in G2, P=0.06. Patients in G2 had a higher CH score (4.1+/-2.7 versus 3.0+/-2.5, P<0.01), and a higher number of patients regretting surgery (11.4% versus 3.6%, P=0.05). Multivariate analysis showed age, high CH score, and surgery on T2 as independent predictors of patient's dissatisfaction (P<0.05). Patients with more than one ganglion transected demonstrate a trend toward a higher incidence of CH, a significantly higher CH score, and are more dissatisfied with ETS. Age, surgery on T2, and high CH score are independent predictors of patient's dissatisfaction.

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.

Sustained benefit lasting one year from T4 instead of T3-T4 sympathectomy for isolated axillary hyperhidrosis

INTRODUCTION

Level T4 video-assisted thoracoscopic sympathectomy proved superior to T3-T4 treatment for controlling axillary hyperhidrosis at the initial and six-month follow-ups of these patients.

OBJECTIVE

To compare the results of two levels of sympathectomy (T3-T4 vs. T4) for treating axillary sudoresis over one year of follow-up.

METHODS

Sixty-four patients with axillary hyperhidrosis were randomized to denervation of T3-T4 or T4 alone and followed prospectively. All patients were examined preoperatively and were followed postoperatively for one year. Axillary hyperhidrosis treatment was evaluated, along with the presence, location, and severity of compensatory hyperhidrosis and self-reported quality of life.

RESULTS

According to patient reports after one year, all cases of axillary hyperhidrosis were successfully treated by surgery. There were no instances of treatment failure. After six months, compensatory hyperhidrosis was present in 27 patients of the T3-T4 group (87.1%) and in 16 patients of the T4 group (48.5%). After one year, all T3-T4 patients experienced some degree of compensatory hyperhidrosis, compared to only 14 patients in the T4 group (42.4%). In addition, compensatory hyperhidrosis was less severe in the T4 patients (p < 0.01). Quality of life was poor before surgery, and it improved in both groups at six months and one year of follow-up (p = 0.002). There were no cases of mortality, no significant postoperative complications, and no need for conversion to thoracotomy in either group.

CONCLUSION

Both techniques were effective for treating axillary hyperhidrosis, but the T4 group showed milder compensatory hyperhidrosis and greater patient satisfaction at the one-year follow-up.

Axillary hyperhidrosis: T3/T4 versus T4 thoracic sympathectomy in a series of 276 cases

BACKGROUND

Different techniques of video-assisted thoracic sympathectomy have been suggested to control the symptoms of axillary hyperhidrosis. We compared the results using two different levels of ganglion resection for treating axillary hyperhidrosis: T3/T4 vs. T4.

MATERIALS AND METHODS

From a group of 1119 patients operated on between July 2000 and January 2005, 276 patients with axillary hyperhidrosis were studied. The mean age was 26 (range, 13-54 years) and 61.6% were female. Of these patients, 216 (78.3%) were treated with thermal ablation of T3/T4 and 60 (21.7%) with thermal ablation of T4 alone. The procedures were bilateral and simultaneous, using two 5.5-mm trocars and 30-degree optical systems, under general anesthesia in all cases.

RESULTS

There was no mortality and no important postoperative complications or need to convert to thoracotomy in either group. The mean follow-up in the T4 group was 11 months (range, 2-23 months) and in the T3/T4 group mean follow-up was 24 months (range, 13-54 months). The immediate therapeutic success rate was 100% in both groups. There were recurrences in 7 (2.5%) patients, all from the T3/T4 group. The satisfaction rate was higher and more stable in the T4 group and compensatory sweating was lower in the T4 group.

CONCLUSION

Both techniques proved effective for controlling the axillary symptoms. Group T4 presented a higher satisfaction rate, lower recurrence rate, and lower severity of compensatory sweating.

A randomized trial of T3-T4 versus T4 sympathectomy for isolated axillary hyperhidrosis

INTRODUCTION

Video-assisted thoracic sympathectomy (VATS) is one minimally invasive definitive treatment for axillary hyperhidrosis. Different techniques exist for controlling axillary sudoresis, but they are temporary and have high cost. This study was conducted to compare the initial results from sympathectomy using two distinct levels for treating axillary sudoresis: T3-T4 vs T4.

METHODS

Sixty-two patients with axillary hyperhidrosis were prospectively randomized for denervation of T3-T4 or T4 alone. All patients were examined preoperatively and were followed-up at 1 and 6 months postoperatively. Evaluated were the axillary hyperhidrosis treatment, the presence, location, and severity of compensatory hyperhidrosis, and the quality of life.

RESULTS

All the patients said that their axillary hyperhidrosis was successfully treated by the surgery after 6 months. There was no treatment failure. Compensatory hyperhidrosis was present in 29 patients (90.6%) of the T3-T4 group and in 17 T4 patients (56.7%) after 1 month. After 6 months, all the T3-T4 patients presented some degree of compensatory hyperhidrosis vs 13 T4 patients (43.3%). The severity of the compensatory hyperhidrosis was also lower in the T4 patients (P < . 01). The quality of life was poor in both groups before the surgery, and was equally improved in both groups after 1 and 6 months of follow-up. There were no deaths or significant postoperative complications nor a need for conversion to thoracotomy.

CONCLUSION

Both techniques are effective for treating axillary hyperhidrosis, but the T4 group presented milder compensatory hyperhidrosis and had a greater satisfaction rate.

Endoscopic VATS sympathectomy: the uniportal technique

Presentation of the uniportal VATS sympathectomy technique: through a single port incision, a videothoracoscope, a diathermy hook and, if needed, a lung grasper are introduced into the pleural cavity. Upon identification of the sympathetic chain, the relevant ganglia are divided. By extending laterally the dissection, the aberrant accessory sympathetic nerve fibers are also severed. Anatomic variations are illustrated and an overview of the literature is presented.