Thoracic Endoscopic Surgery for Hyperhidrosis: Comparison of Different Techniques

A multicentre retrospective study of lumbar sympathectomy for plantar hyperhidrosis: satisfaction and postoperative complications

BACKGROUND

Primary plantar hyperhidrosis has a severe impact on quality of life and conservative treatments are only effective in the short term. Thoracic sympathectomy has proven its effectiveness in the treatment of palmar hyperhidrosis, but lumbar sympathectomy for plantar hyperhidrosis remains poorly described.

OBJECTIVES

To report the satisfaction of patients with primary plantar hyperhidrosis treated with mechanical lumbar sympathectomy as well as their postoperative complications.

METHODS

This was a multicentre retrospective observational study of 16 patients with primary plantar hyperhidrosis, treated with mechanical lumbar sympathectomy from December 2012 to October 2022. Patients' characteristics were collected from medical records. Quality of life, postoperative satisfaction and complications were evaluated using a standardized questionnaire.

RESULTS

Lumbar sympathectomy was performed on 16 patients, 14 were women and 2 were men with a total of 31 procedures. Fourteen (88%) patients were satisfied and would recommend the surgery to other patients. Compensatory hyperhidrosis occurred in 75% of patients, recurrence of hyperhidrosis in 31% and sexual dysfunction in 19%.

CONCLUSIONS

Lumbar sympathectomy provides satisfying results for plantar hyperhidrosis with acceptable postoperative complications, regardless of sex. Compensatory hyperhidrosis was the most frequent complication but had no impact on patient satisfaction. In the literature, data on the risk of sexual dysfunction are reassuring and in our study only one of two men experienced transient ejaculation disorder.

Thoracoscopic resympathectomy for persistent or recurrent palmar hyperhidrosis: single-center experience

BACKGROUND

In case of recurrence or persistent palmar hyperhidrosis, a sympathetic chain resection is suggested, however, many surgeons are still reluctant to offer further intervention because of the inability to predict the efficacy of such a procedure. We analyzed our large series of resympathectomy.

METHODS

Substantive retrospective analysis of 39 patients underwent a resympathectomy (minimally invasive bilaterally sympathetic chain Th2-3 resection). Patients referred from other hospitals or primarily operated at our institution for recurrence or persistence palmar hyperhidrosis were included in the study group.

RESULTS

No intraoperative complications were detected. Reoperation or chest tube positioning was necessary in 2 patients. Twenty-eight patients had a positive response (excellent or good results). Seven patients described a substantial, but not sufficient, reduction of the symptomatology. Four patients were very unsatisfied and regretted the operation.

CONCLUSIONS

Resympathectomy is highly effective procedure for patients who have persistent or recurrent symptoms. However, the indication of the operations should be more dissuasive as possible to avoid the risk of any undesirable psychologically side effects.

Effectiveness of unilateral sequential video-assisted sympathetic chain blockage for primary palmar hyperidrosis in children and adolescents

INTRODUCTION

Primary palmar hyperhidrosis (PPH) is a severely debilitating condition that can affect patients of any age. Thoracoscopic sympathectomy provides a definitive treatment for PPH. Aim of this study is to investigate the effectiveness of unilateral sequential video-assisted thoracic sympathetic chain clamping (VATSCC) by clips application in pediatric population.

METHODS

The surgical procedure was done in the semi-sitting position, under general anesthesia with orotracheal intubation. Mean operation time was 23 ± 6 min (range 12-45). Two 5 mm ports were inserted at the level of the middle axillary line in the second and fourth intercostal space respectively. The sympathetic chain was identified, and two clips were applied, the first one at the level of the third and the second one, at the level of the fourth rib. No chest tube was used. Resolution of symptoms, complications, recurrence rate, onset and duration of compensatory hyperhidrosis were analyzed.

RESULTS

From August 2017 to September 2021, 58 patients (male:female ratio 32:26), mean age 16.5 years (range 14-19), with PPH underwent unilateral sequential VATSCC by clips application, starting on the dominant hand. The contralateral side was operated 2 months after. All patients except one (transient pneumothorax) were discharged on the first post-op day. No immediate or late complications have been recorded. Mean follow-up was 32 months (range 6-41). All patients except one (1,7%), affected by Raynaud's disease, showed a complete resolution of the symptom. Seven patients (12%) developed transient moderate compensative hyperhidrosis (CH) that spontaneously disappeared in the postoperative period.

CONCLUSIONS

Unilateral sequential thoracoscopic sympathetic chain clamping for PPH in pediatric patients is a safe and very effective procedure with a low complication rate and low incidence of postoperative CH that, in our experience, resolved spontaneously in the postoperative period, after the second surgery leading to an improvement in the quality of life.

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.

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.

Thoracic sympathectomy for hyperhidrosis: from surgical indications to clinical results

Sympathectomy and its variations have been performed in thoracic surgery for more than 100 years. However, its indications have undergone profound modifications in this period. Likewise, since then the surgical technique has also evolved dramatically up to the minimally invasive techniques worldwide accessible in present days. Currently, primary hyperhidrosis is, by far, the main indication for thoracic sympathectomy and this procedure is usually carried out thoracoscopically with excellent results. However, until today, hyperhidrosis is a part of thoracic surgery still surrounded by controversy, persisting as an open field over which some confusion still resides regarding its pathophysiology, terms definitions and operative approaches. The aim of this article is to provide a wide but easily comprehensible review of the theme, discussing and clarifying the major concepts with respect to its clinical presentation, all the presently available treatment options and strategies with their potential benefits and risks, the adequate patient selection for sympathectomy, as well as the postoperative clinical results.

Outcome of Limited Video-Assisted Lumbar Sympathetic Block for Plantar Hyperhidrosis Using Clipping Method

BACKGROUND

There are many ways to treat focal hyperhidrosis, including surgeries for palmar and axillary hyperhidrosis. However, doctors and patients tend to be reluctant to perform surgery for plantar hyperhidrosis due to misconceptions and prejudices about surgical treatment. In addition, few studies have reported the outcome of surgeries for plantar hyperhidrosis. Therefore, the objective of this study was to determine the outcome (early and late postoperative satisfaction, complication, compensatory hyperhidrosis, recurrence rate, and efficiency) of surgical treatment for plantar hyperhidrosis.

MATERIALS AND METHODS

From August 2014 to October 2015, lumbar sympathetic block (LSB) was performed in 82 patients with plantar hyperhidrosis using clipping method. Limited video-assisted LSB was performed using 5 mm ligamax-clip or 3 mm horizontal-clip after identifying L3-4 sympathetic ganglion through finger-touch and endoscopic vision.

RESULTS

Of the 82 patients, 45 were male and 37 were female. Their mean age was 26.38 years (range, 14-51 years). Mean follow-up time was 6.60 ± 3.56 months. Mean early postoperative satisfaction score was 9.6 on the 10th day postoperative evaluation. At more than 1 month later, the mean late postoperative satisfaction score was 9.2. There was no significant difference in early postoperative satisfaction score between clipping level L3 and L4/5. However, late postoperative satisfaction score was significantly better in the L3 group than that in the L4/5 group. Patient's age and body mass index did not affect the satisfaction score. However, male patients and patients who had history of hyperhidrosis operation showed higher satisfaction score than others.

CONCLUSION

Limited video-assisted LSB using clip provided good results with minimal complications and low compensatory hidrosis, contrary to the prejudice toward it. Therefore, surgical treatment is recommended for plantar hyperhidrosis.

Compensatory sweating after restricting or lowering the level of sympathectomy: a systematic review and meta-analysis

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.

Quality of life after sympathetic surgery at the T4 ganglion for primary hyperhidrosis: clip application versus diathermic cut

INTRODUCTION

Limited procedures at the T4 ganglion show low rates of compensatory sweating (CS). The aim of the study was to compare endoscopic sympathetic block (ESB) via clip application with endothoracic sympathicotomy (ETS) via diathermy with special regard on patients' quality of life (Qol).

PATIENTS AND METHODS

Treatment success, side effects and patient satisfaction were evaluated in a prospectively gathered database of a tertiary-care referral hospital. Two disease-specific Qol questionnaires were used (Keller, Milanez de Campos).

RESULTS

406 operations were performed in 205 patients (ESB4 N = 114, ETS4 N = 91) with a median follow-up of 12 months. Both procedures improved Qol significantly (P < 0.001) and the degree of improvement was equal in both groups. Palmar and axillary HH were ameliorated after both procedures (P < 0.001). Accordingly, plantar HH decreased after ESB4 (P = 0.002), while remaining unaltered after ETS4. Nineteen patients (9.3%) reported CS and 10 patients (4.9%) judged it as "disturbing". Nine of the latter belonged to the ETS4 group compared to one ESB patient (P = 0.015). Patients developed higher rates of plantar CS after ETS4 compared to ESB4 (P = 0.006). Five patients (2.4%) from both cohorts reported persistence of axillary HH. Recurrence of axillary symptoms was found in 5 ESB4 patients. Satisfaction rates did not differ significantly.

CONCLUSION

Patients' Qol and satisfaction rates are similar in both treatment groups for upper limb HH. Outcome and recurrence rates speak in the favor of ETS4, severity of CS and potential reversibility argue for ESB4.

Long-term outcomes associated to video-assisted thoracic sympathotomy for palmar-axillar subtype of the hyperhidrosis

OBJECTIVE

Surgery for both palmar and axillar hyperhidrosis usually includes the interruption of the sympathetic chain in multiple levels. This study aimed to determine the long-term outcomes associated to video-assisted thoracic sympathotomy (VATS) of T2, T3 and T4 ganglia for these cases.

METHODS

Analysis of the outcomes obtained from 36 patients regarding the rate of resolution of the symptoms and the compensatory sweating (CS). All subjects were followed-up for 36 months.

RESULTS

Good outcomes were observed in 98.6% for palmar and 60% for axillary hyperhidrosis (p=0.0423), respectively. Of the subjects, 86% reported some postoperative episode of CS, however only 45% (p=0.0031) still noticed it at the end of the follow-up period.

CONCLUSIONS

VATS is effective for the excessive palmar sweating, whereas it is fully efficient for only two thirds of the cases sustaining associated axillar hyperhidrosis. CS is expected as a rule following the proposed operative protocol, however it is usually self-limited.

[Initial experience of a program of clipping the sympathetic nervous system for the treatment of hyperhidrosis and facial flush]

INTRODUCTION AND OBJECTIVE

To evaluate the results of our program of clipping the thoracic sympathetic nervous system (TSNS) for the treatment of facial flush and/or hyperhidrosis (HH), and to compare the methodology-results of the program development phase (A: January 2007-April 2009) and its consolidation phase (B: May 2009-March 2010).

MATERIAL AND METHODS

The program included a total of 44 patients (88 procedures) subjected to videothoracoscopy and clipping of the TSNS in a one day surgery unit. Data were collected and analysed retrospectively, and a descriptive and comparative statistical analysis was performed between the two periods (A and B).

RESULTS

The overall morbidity was 5 cases (11.3%). The post-surgical occurrence rate of HH was 4.54% (2 cases), and the incidence of compensatory sweating was 65.9% (minimal in 26 of the 29 cases). On comparing period B with period A, there was a significant decrease in surgical time, disappearance of recurrence of HH, a decrease of 30% in morbidity, reduction by half in the incidence of moderate to severe compensatory sweating, and an increase in the level of satisfaction. The clamps were removed in one of the poorly tolerated compensatory sweating cases, resulting in its disappearance.

CONCLUSIONS

Clipping the TSNS is a safe technique in the one day surgery unit, with a short learning curve (20 cases) after which comparable, or even better, results are obtained than those of sympatholysis. These results, together with their potential reversibility, makes it, in our opinion, the technique of choice in the surgery of the TSNS.

Primary focal hyperhidrosis: current treatment options and a step-by-step approach

Primary focal hyperhidrosis is a common disorder for which treatment is often a therapeutic challenge. A systematic review of current literature on the various treatment modalities for primary focal hyperhidrosis was performed and a step-by-step approach for the different types of primary focal hyperhidrosis (axillary, palmar, plantar and craniofacial) was established. Non-surgical treatments (aluminium salts, local and systemic anticholinergics, botulinum toxin A (BTX-A) injections and iontophoresis) are adequately supported by the current literature. More invasive surgical procedures (suction curettage and sympathetic denervation) have also been extensively investigated, and can offer a more definitive solution for cases of hyperhidrosis that are unresponsive to non-surgical treatments. There is no consensus on specific techniques for sympathetic denervation, and this issue should be further examined by meta-analysis. There are numerous treatment options available to improve the quality of life (QOL) of the hyperhidrosis patient. In practice, however, the challenge for the dermatologist remains to evaluate the severity of hyperhidrosis to achieve the best therapeutic outcome, this can be done most effectively using the Hyperhidrosis Disease Severity Scale (HDSS).

[Primary hyperhidrosis. Current status of surgical treatment]

Primary hyperhidrosis-PH is an excessive sweating without known etiology. The PH is more frequent in women and in palms, soles and axillae. Medical treatment is not effective. The objective of the surgery is to remove or to disconnect sympathetic ganglia T2 (craniofacial PH or facial blushing), T3 (palmar PH) and T3-T4 (axillary PH). The surgical techniques are mainly resection/transection, ablation with electrocoagulation, sympathetic block by clipping and radiofrequency. Anhidrosis is achieved in 95% of the patients. The overall rate of complications is less than 5% and these are minor complications. The most important unwanted effect is reflex sweating, presented in 48% of the patients. Reflex sweating is more frequent in back, thorax and abdomen and it appears independently of the surgical technique. Ninety percent of the patients are very satisfied after surgery. Nowadays, thoracic sympathetic surgery is the gold standard for primary hyperhidrosis.