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Ho AVT, Øvensen E, Lilja D, Toska K, Grenager O, Kristiansen K, Wesche J. Changes in electrodermal activity following sympathicotomy in hyperhidrosis patients. Front Surg 2024; 11:1358357. [PMID: 38529470 PMCID: PMC10961364 DOI: 10.3389/fsurg.2024.1358357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/22/2024] [Indexed: 03/27/2024] Open
Abstract
Objectives The aim of this study was to assess the potential of electrodermal activity (EDA) as a diagnostic tool for preoperative evaluation in hyperhidrosis patients. EDA levels and patterns in different skin areas were investigated before and after endoscopic thoracic sympathicotomy (ETS) and was compared to healthy subjects. Methods Thirty-seven patients underwent two days of measurements before and after the operation. Twenty-five (67.5%) of the patients also had a third measurement after six months. Non-invasive EDA measurements, involving skin conductance, were sampled from five different skin areas while patients were at rest in supine and sitting positions or when subjected to stimuli such as deep inspirations, mental challenge, and exposure to a sudden loud sound. Results Prior to the operation, hyperhidrosis patients showed higher spontaneous palm EDA variations at rest and stronger responses to stimuli compared to healthy subjects. Patients with facial blushing/hyperhidrosis or combined facial/palmar hyperhidrosis showed minimal spontaneous activity or responses, particularly during mental challenge and sound stimulus. Notably, palm EDA response was abolished shortly following sympathicotomy, although a minor response was observed after six months. Minimal EDA responses were also observed in the back and abdomen postoperatively. Conclusion Hyperhidrosis patients showed stronger EDA response to stimuli compared to healthy subjects. Sympathicotomy resulted in the complete elimination of palm EDA responses, gradually returning to a limited extent after six months. These findings suggest that EDA recordings could be utilized in preoperative assessment of hyperhidrosis patients.
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Affiliation(s)
- Ai Van Thuy Ho
- The Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Thoracic and Vascular Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Eirik Øvensen
- Department of Thoracic and Vascular Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Didrik Lilja
- The Intervention Centre, Oslo University Hospital, Oslo, Norway
| | - Karin Toska
- The Faculty of Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Odd Grenager
- Department of Thoracic and Vascular Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Knut Kristiansen
- Department of Thoracic and Vascular Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Jarlis Wesche
- The Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Thoracic and Vascular Surgery, Akershus University Hospital, Lørenskog, Norway
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Dittberner FA, Jørgensen OD, Pilegaard HK, Ladegaard L, Licht PB. Sympathicotomy for isolated facial blushing: long-term follow-up of a randomized trial. Eur J Cardiothorac Surg 2024; 65:ezad414. [PMID: 38085236 DOI: 10.1093/ejcts/ezad414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/01/2023] [Accepted: 12/11/2023] [Indexed: 03/12/2024] Open
Abstract
OBJECTIVES Thoracoscopic sympathicotomy may be an effective treatment for disabling facial blushing in selected patients. Short- and mid-term results are good but very long-term results are scarce in the medical literature and there is no knowledge which extent of sympathicotomy is better long-term for isolated facial blushing. METHODS We previously randomized 100 patients between a rib-oriented R2 or R2-R3 sympathicotomy for isolated facial blushing, and reported local effects, side effects and quality of life after 12 months. In the present study, we sent identical questionnaires to all patients after a median of 16 years (interquartile range 15-17 years). RESULTS The response rate was 66%. Overall, 82% reported excellent or satisfactory results on facial blushing, with significant better local effect after R2 sympathicotomy compared with R2-R3 sympathicotomy. Patients who underwent R2 sympathicotomy were also significantly more satisfied with the operation. We found no significant difference between R2 and R2-R3 sympathicotomy in quality of life or rates of compensatory sweating (77%) and recurrence of blushing (41%) which was milder than preoperatively in most patients. CONCLUSIONS R2 sympathicotomy should be the preferred approach for isolated facial blushing because of better local effect and higher satisfaction rates. Although this was a very long-term follow-up of the only randomized trial of its kind the response rate was limited leaving a risk of undetected bias.
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Affiliation(s)
- Finn Amundsen Dittberner
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Skejby, Denmark
| | - Ole Dan Jørgensen
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Skejby, Denmark
| | - Hans Kristian Pilegaard
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Skejby, Denmark
| | - Lars Ladegaard
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Skejby, Denmark
| | - Peter Bjørn Licht
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Skejby, Denmark
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Park JK, Hyun K, Moon MH, Lee J. Surgical treatment of facial blushing: Patient selection and operative technique (retrospective observational study). Medicine (Baltimore) 2022; 101:e29808. [PMID: 35801793 PMCID: PMC9259148 DOI: 10.1097/md.0000000000029808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Surgeons are often reluctant to offer further intervention to patients with medically intractable facial blushing. This is mainly because of the relatively high failure rate of blushing resolution and a high incidence of compensatory hyperhidrosis. In this study, we sought to identify the type of blushing that would benefit from surgery and minimize compensatory hyperhidrosis by applying diffuse sympathicotomy (DS). This study was a retrospective review of 62 patients who underwent R2 endoscopic thoracic sympathicotomy (ETS) and preemptive DS for facial blushing. Facial blushing was classified as autonomic-mediated blushing (thermoregulatory, emotional) and vasodilator-mediated blushing (constant) based on the history and precipitating factors for blushing. DS was performed at lower-thoracic levels in the form of limited DS (right R5/7/9/11, left R5/6/8/10) or extended DS (bilateral R5-11). Resolution of blushing (described as "almost disappeared") was achieved in 48% of patients with a median follow-up of 19.6 months. There was a significant difference in resolution among 3 types of blushing (emotional: 55%, thermoregulatory: 28%, constant: 15%, P = .03). Multivariate analysis confirmed thermoregulatory and constant type blushing as a potential independent predictor of blushing resolution. Even though there was no difference between the DS procedures with respect to compensatory hyperhidrosis, intolerable compensatory hyperhidrosis (Hyperhidrosis Disease Severity Scale = 4) occurred in only 11% of patients. DS redistributed sweating area, being predominantly on the chest and mid-back (89%), also seen on the abdomen-waist-groin-buttocks-thighs (63%). Overall, 77% of patients experienced satisfactory results. Emotional blushing proved to be an established indication of ETS where good long-term results can be expected. Expansion of surgical indication to thermoregulatory or constant type blushing needs to be validated in future studies. Additionally, compensatory hyperhidrosis, another hurdle for ETS, can be minimized by preemptive DS, resulting in redistribution and decrease of sweating.
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Affiliation(s)
- Jae Kil Park
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary’s Hospital, Catholic University of Korea, Seoul, South Korea
| | - Kwanyong Hyun
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary’s Hospital, Catholic University of Korea, Seoul, South Korea
- *Correspondence: Kwanyong Hyun, Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary’s Hospital, Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, South Korea (e-mail: )
| | - Mi Hyoung Moon
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary’s Hospital, Catholic University of Korea, Seoul, South Korea
| | - Jungsun Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary’s Hospital, Catholic University of Korea, Seoul, South Korea
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Kuijpers M, van Zanden JE, Harms PW, Mungroop HE, Mariani MA, Klinkenberg TJ, Bouma W. Minimally Invasive Sympathicotomy for Palmar Hyperhidrosis and Facial Blushing: Current Status and the Hyperhidrosis Expert Center Approach. J Clin Med 2022; 11:jcm11030786. [PMID: 35160238 PMCID: PMC8836383 DOI: 10.3390/jcm11030786] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/28/2022] [Accepted: 01/29/2022] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Michiel Kuijpers
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.E.v.Z.); (H.E.M.); (M.A.M.); (T.J.K.); (W.B.)
- Hyperhidrosis Expert Center, Dermatology, Martini Hospital, 9700 RM Groningen, The Netherlands;
- Correspondence:
| | - Judith E. van Zanden
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.E.v.Z.); (H.E.M.); (M.A.M.); (T.J.K.); (W.B.)
| | - Petra W. Harms
- Hyperhidrosis Expert Center, Dermatology, Martini Hospital, 9700 RM Groningen, The Netherlands;
| | - Hubert E. Mungroop
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.E.v.Z.); (H.E.M.); (M.A.M.); (T.J.K.); (W.B.)
- Hyperhidrosis Expert Center, Dermatology, Martini Hospital, 9700 RM Groningen, The Netherlands;
| | - Massimo A. Mariani
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.E.v.Z.); (H.E.M.); (M.A.M.); (T.J.K.); (W.B.)
- Hyperhidrosis Expert Center, Dermatology, Martini Hospital, 9700 RM Groningen, The Netherlands;
| | - Theo J. Klinkenberg
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.E.v.Z.); (H.E.M.); (M.A.M.); (T.J.K.); (W.B.)
- Hyperhidrosis Expert Center, Dermatology, Martini Hospital, 9700 RM Groningen, The Netherlands;
| | - Wobbe Bouma
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.E.v.Z.); (H.E.M.); (M.A.M.); (T.J.K.); (W.B.)
- Hyperhidrosis Expert Center, Dermatology, Martini Hospital, 9700 RM Groningen, The Netherlands;
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Girish G, D'souza RE, D'souza P, Lewis MG, Baker DM. Role of surgical thoracic sympathetic interruption in treatment of facial blushing: a systematic review. Postgrad Med 2017; 129:267-275. [PMID: 28116967 DOI: 10.1080/00325481.2017.1283207] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES This paper aims to review the evidence to support the effectiveness of sympathectomy as a treatment for facial blushing in terms of relief of facial blushing, patient satisfaction, recurrence of blushing, patients regretting treatment and its associated complications. METHODS A systematic search strategy was performed in Ovid-Medline, Embase, Cochrane library and NICE. Studies reporting outcomes of sympathetic interruption in the treatment of facial blushing were retrieved. RESULTS Nine studies met the inclusion criteria with 1369 patients included in the final analysis. The age range of patients was 8 to 74 years (from 7 studies) with 56% females. Mean follow up was 21 months in 8 studies (range 6 to 30 months). The pooled proportion of patients who had good relief of facial blushing was 78.30% (95% C.I. 58.20% - 98.39%). Complete satisfaction was reported in 84.02% (95% C.I. 71.71% - 96.33%). Compensatory sweating and gustatory sweating were the commonest complications occurring in 74.18% (95% C.I. 58.10% - 90.26%) and 24.42% (95% C.I. 12.22% - 36.61%) respectively. The estimated proportion of patients regretting surgery was 6.79% (C.I 2.08% 11.50%). CONCLUSION Sympathetic interruption at T2 or T2-3 ganglia appears to be an effective treatment for facial blushing. However, lack of randomized trials comparing sympathetic interruption with non-surgical methods of treatment and heterogeneity of included studies with respect to assessment of outcome measures preclude strong evidence and definitive recommendations.
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Affiliation(s)
- Girish Girish
- a Consultant in general and vascular surgery, Department of General & Vascular Surgery , Watford General Hospital , Watford , UK
| | - Rovan E D'souza
- b Consultant in general and vascular surgery, Department of Vascular Surgery , Royal Free Hospital, Royal Free London NHS Foundation Trust , London , UK
| | - Preethy D'souza
- c Research Associate, Social Science Research Unit and EPPI-Centre , UCL Institute of Education , London , UK
| | - Melissa G Lewis
- d Research scholar, Department of statistics , Public Health Evidence, South Asia (PHESA), Manipal University , Manipal , India
| | - Daryll M Baker
- b Consultant in general and vascular surgery, Department of Vascular Surgery , Royal Free Hospital, Royal Free London NHS Foundation Trust , London , UK
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Abstract
Facial blushing, associated with social phobia, may have severe negative impact on the quality of daily life. The first line of treatment should be psychological and/or pharmacologic. In severe cases not responding to nonsurgical treatment, surgical sympathetic denervation is an option. A thorough disclosure of effects, complications, and side effects is mandatory and patient selection is crucial to obtain high patient satisfaction from surgical treatment.
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Hashmonai M, Cameron AEP, Licht PB, Hensman C, Schick CH. Thoracic sympathectomy: a review of current indications. Surg Endosc 2015; 30:1255-69. [PMID: 26123342 DOI: 10.1007/s00464-015-4353-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 06/16/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Thoracic sympathetic ablation was introduced over a century ago. While some of the early indications have become obsolete, new ones have emerged. Sympathetic ablation is being still performed for some odd indications thus prompting the present study, which reviews the evidence base for current practice. METHODS The literature was reviewed using the PubMed/Medline Database, and pertinent articles regarding the indications for thoracic sympathectomy were retrieved and evaluated. Old, historical articles were also reviewed as required. RESULTS AND CONCLUSIONS Currently, thoracic sympathetic ablation is indicated mainly for primary hyperhidrosis, especially affecting the palm, and to a lesser degree, axilla and face, and for facial blushing. Despite modern pharmaceutical, endovascular and surgical treatments, sympathetic ablation has still a place in the treatment of very selected cases of angina, arrhythmias and cardiomyopathy. Thoracic sympathetic ablation is indicated in several painful conditions: the early stages of complex regional pain syndrome, erythromelalgia, and some pancreatic and other painful abdominal pathologies. Although ischaemia was historically the major indication for sympathetic ablation, its use has declined to a few selected cases of thromboangiitis obliterans (Buerger's disease), microemboli, primary Raynaud's phenomenon and Raynaud's phenomenon secondary to collagen diseases, paraneoplastic syndrome, frostbite and vibration syndrome. Thoracic sympathetic ablation for hypertension is obsolete, and direct endovascular renal sympathectomy still requires adequate clinical trials. There are rare publications of sympathetic ablation for primary phobias, but there is no scientific basis to support sympathetic surgery for any psychiatric indication.
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Affiliation(s)
- Moshe Hashmonai
- Faculty of Medicine, Technion-Israel Institute of Technology, PO Box 359, 30952119, Zikhron Ya'akov, Haifa, Israel.
| | | | - Peter B Licht
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
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Coveliers H, Hoexum F, Rauwerda JA, Wisselink W. Endoscopic thoracic sympathectomy for upper limb ischemia. A 16 year follow-up in a single center. Surgeon 2015; 14:265-9. [PMID: 25900032 DOI: 10.1016/j.surge.2015.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 03/24/2015] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The aim of our study was to evaluate the long term results of Endoscopic Thoracic Sympathectomy (ETS) in the management of upper limb ischemia (ULI). METHODS We retrospectively reviewed the records of all consecutive patients who underwent ETS for ULI between January 1994 and May 2009. A standardized questionnaire was used to evaluate the long term success, morbidity and overall patient satisfaction. RESULTS Thirty-five patients (20 female, mean age 49 years (range 23-79)) underwent bilateral (n = 9) and unilateral (n = 27) ETS procedures, respectively. Six patients had Primary (idiopathic) Raynaud Disease. Twenty-nine patients had upper limb ischemia secondary to systemic disorders (n = 12), embolic disease (n = 10), occlusion of the arteries of the arm (n = 5) or hypothenar hammer syndrome (n = 2). Tissue loss at time of surgery was present in nineteen patients. Short term beneficial effects were reported by 12 patients (63%). Eleven of the 35 patients experienced a total of 13 complications or adverse events, whereof 11 were minor or transient. Limb salvage was unsuccessful in three patients because of major amputations (n = 2) or severe functional impairment (n = 1). Necrotectomies or minor amputations without functional impairment were performed in 9 patients. Medium or long term follow up (mean 98 months (range 18-198) was available in 19 out of 22 living patients(86%). Long term beneficial effects were reported by 10 (53%). Overall patient satisfaction was 56%. Compensatory sweating was experienced by 11 patients (58%). CONCLUSION Although the long term efficacy of ETS in our study was moderate (53%), due to its low invasiveness ETS is a valuable option in the management of ULI.
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Affiliation(s)
- Hans Coveliers
- Department of Vascular Surgery, VU Medical Center, Amsterdam, The Netherlands.
| | - Frank Hoexum
- Department of Vascular Surgery, VU Medical Center, Amsterdam, The Netherlands
| | - Jan A Rauwerda
- Department of Vascular Surgery, VU Medical Center, Amsterdam, The Netherlands
| | - Willem Wisselink
- Department of Vascular Surgery, VU Medical Center, Amsterdam, The Netherlands
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Cai SW, Shen N, Li DX, Wei B, An J, Zhang JH. Compensatory sweating after restricting or lowering the level of sympathectomy: a systematic review and meta-analysis. Clinics (Sao Paulo) 2015; 70:214-9. [PMID: 26017654 PMCID: PMC4449481 DOI: 10.6061/clinics/2015(03)11] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Accepted: 01/05/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To compare compensatory sweating after lowering or restricting the level of sympathectomy. METHOD A systematic review and meta-analysis were conducted of all randomized controlled trials published in English that compared compensatory sweating after lowering or restricting the level of sympathectomy. The Cochrane collaboration tool was used to assess the risk of bias, and the Mantel-Haenszel odds ratio method was used for the meta-analysis. RESULTS A total of 11 randomized controlled trials were included, including a total of 1079 patients. Five of the randomized controlled trials studied restricting the level of sympathectomy, and the remaining six studied lowering the level of sympathectomy. CONCLUSIONS The compiled randomized controlled trial results published so far in the literature do not support the claims that lowering or restricting the level of sympathetic ablation results in less compensatory sweating.
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Affiliation(s)
- Song-Wang Cai
- Department of Cardiothoracic Surgery, Sun Yat-sen University, Guangzhou, China
| | - Ning Shen
- Department of Anesthesiology, Sun Yat-sen University, Guangzhou, China
| | - Dong-Xia Li
- School of Basic Medical Sciences, Xinxiang Medical University, Xinxiang, China
| | - Bo Wei
- Department of Gastrointestinal Surgery, Sun Yat-sen University, Guangzhou, China
| | - Jun An
- Department of Cardiothoracic Surgery, Sun Yat-sen University, Guangzhou, China
| | - Jun-Hang Zhang
- Department of Cardiothoracic Surgery, Sun Yat-sen University, Guangzhou, China
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Low DE. Invited commentary. Ann Thorac Surg 2012; 94:405. [PMID: 22818301 DOI: 10.1016/j.athoracsur.2012.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 04/11/2012] [Accepted: 04/12/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Donald E Low
- Department of Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA 98111, USA.
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