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Ann Thorac Surg 1999;68:1177-1181
© 1999 The Society of Thoracic Surgeons

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Original Articles

Video assistance reduces complication rate of thoracoscopic sympathicotomy for hyperhidrosis

^a University Clinic of Surgery, Vienna General Hospital, Vienna, Austria

Address reprint requests to Dr Zacherl, University Clinic of Surgery, AKH 21.A, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
e-mail: johannes.zacherl{at}akh-wien.ac.at

	Abstract

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Background. Thoracoscopic sympathicotomy has proved successful in the treatment of palmar hyperhidrosis. However, up to 8% of patients experience Horner’s syndrome, and about 50% show compensatory sweating. This study evaluates the role of video assistance in thoracoscopic sympathicotomy for primary hyperhidrosis of the upper limb.

Methods. Six hundred fifty-six thoracoscopic sympathicotomies were performed from below T1 to T4 in 369 patients. Of the operations, 558 were done under direct view (CTS group) and 98, with video assistance (VATS group). Follow-up was complete for 78.3% of patients after a median observation period of 16 years.

Results. Dry limbs were immediately achieved in 93% of the CTS group and 98% VATS group (p = 0.98). In the CTS group, Horner’s syndrome occurred after 2.2% of all operations and rhinitis in 8.3%. No patient in the VATS group showed any symptom of Horner’s triad (p = 0.03 versus CTS group) or rhinitis (p = 0.02 versus CTS group). Compensatory sweating was observed in 66.8% in the CTS group versus 69% in the VATS group (p = 0.73) and gustatory sweating, in 50.4% versus 27.6%, respectively (p = 0.01).

Conclusions. In performing thoracoscopic sympathicotomy for excessive upper-limb hyperhidrosis, we observed a significant decrease in the incidence of Horner’s syndrome, rhinitis, and gustatory sweating when the procedure was guided by video imaging.

	Introduction

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Hyperhidrosis of unknown etiology is successfully treated by severance or resection of the upper thoracic sympathetic chain, thus making surgical intervention the modality of choice in severe cases [1]. Different surgical approaches have been used to reach the thoracic ganglia, T2 and T3 are responsible for sympathetic innervation of the palm, and T4 supplies the axillary region. In Austria in the early 1950s, Kux [2] introduced a minimally invasive access technique using the Jacobaeus method [3] of thoracoscopy to visualize the sympathetic trunk for diathermic severance of the ganglia. Without affecting the rate of success of surgical treatment, the endoscopic procedure reduced the morbidity of sympathectomy, which is the main drawback of the open surgical approach [4, 5]. Many groups [6–11] have since considered the endoscopic procedure the treatment of choice.

Open sympathectomy is often accompanied by a considerably high morbidity. The incidence of Horner’s syndrome, for instance, ranges from 10% to 43% [4, 5]. Damage to the phrenic nerve, the brachial plexus, and the subclavian artery, chylothorax, and pneumomediastinum are other complications after sympathectomy through the supraclavicular open approach. The incidence and the severity of complications after surgical treatment of hyperhidrosis are reported to decline when the operation is performed endoscopically [1, 7, 9, 11–13]. We [13] noted complete or partial Horner’s syndrome in some patients having thoracoscopic sympathicotomy. In 1991, we introduced video assistance in thoracoscopic sympathicotomy, to obtain a better view and to improve the safety of the treatment.

The Kux procedure [2, 13] has been performed at our institution for more than three decades. The aim of the present study was to determine whether video-assisted imaging influences the postoperative morbidity and success of the Kux procedure for upper limb hyperhidrosis.

	Material and methods

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From 1965 to 1997, 656 thoracoscopic sympathicotomies were performed in 369 consecutive patients at our institution. Two hundred eighty-seven patients were operated on bilaterally in two sessions and 82, unilaterally. The median age was 30.2 years (range, 12 to 56 years). Two hundred fifty-one patients had a palmar manifestation, 47 had an isolated axillary manifestation, and 71 patients had combined hyperhidrosis. Conventional thoracoscopic sympathicotomy under direct optical viewing was performed in all patients having operation between 1965 and 1990, namely, 315 patients who underwent 558 procedures (CTS group). From 1991 onward, sympathicotomy was assisted by video imaging and has been used in 98 procedures in 54 patients (VATS group).

Operative technique
The same technique of manipulation was used in all procedures in both groups. After induction of general anesthesia, orotracheal intubation, and lateral positioning of the patient, a pneumothorax of 1,000 mL is achieved using a Veress needle. An 11-mm trocar (Fig 1) is inserted into the pleural cavity in the fourth intercostal space in the midaxillary line. A left-curved or right-curved wire loop electrode brought in through the working thoracoscope (see Fig 1) is used to completely divide the sympathetic trunk (Fig 2) from the level of the second rib down to the T4 ganglion at the level of the ribs including the rami communicantes and the accessory fibers of Kuntz [14], if present. To be sure to sever all the accessory sympathetic fibers, we dissect the pleura along the second rib up to approximately 5 cm lateral to the sympathetic chain. Finally, the pleural cavity is evacuated, and the skin wound is closed under application of continuous positive airway pressure. The operation takes about 20 minutes.

View larger version (29K): [in this window] [in a new window]   Fig 1. Trocar and cannula and thoracoscope. The thoracoscope is a straightforward thoracoscope, 0 degrees, wide angle, with an angled eyepiece (A), a 6-mm instrument channel (B), a port for fiber optic light transmission (C), and a part for a rubber balloon pump (D). For video-assisted procedures, a videocamera is mounted at the eyepiece. (Reproduced with permission of Karl Storz Company, Tuttlingen, Germany).

View larger version (189K): [in this window] [in a new window]   Fig 2. Operative technique. (Top left) The diathermy hook is inserted between the pleura and the sympathetic trunk, and (top right) the pleura is opened by coagulation. (Bottom left) The sympathetic trunk is elevated by the hook and subsequently divided by coagulation. (Bottom right) Result after complete nerve division. (Re- printed from Kux [2] with permission.)

Evaluation
The charts of all 369 patients were reviewed to assess immediate postoperative success and complication rates. In addition, the patients were sent a questionnaire regarding long-term outcome, satisfaction, late complications, and side effects of treatment. A small number of patients who had had operation within the last 3 years were reexamined clinically. Complete and clear information on the long-term outcome of treatment was obtained from 292 patients (79%). Fourteen patients have died, the outcome of 42 patients is unknown, and 21 patients underwent operation less than 6 months before evaluation. The median follow-up is 16.1 years (range, 6 months to 27 years).

Statistical analysis
Significance of differences between groups was calculated using the ² test with respect to the following: incidence of operation failure, pneumothorax, pleural effusion, conversion to thoracotomy, complete or incomplete Horner’s syndrome, compensatory and gustatory sweating, rhinitis, and patient satisfaction. A p value of less than 0.05 was considered significant.

	Results

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The data characterizing the patients in the two groups are highlighted in Table 1. The median age of the patients and the distribution of the different manifestations of hyperhidrosis were almost identical. However, follow-up for the CTS group is longer than that for the VATS group because VATS was not performed till 1991. The follow-up of video-assisted operations is up to 3 years. In neither the CTS group nor the VATS group was repeat thoracoscopy or repeat thoracotomy necessary. In 1 patient in the CTS group, intercostal artery bleeding necessitated conversion to thoracotomy. In the VATS group, we once needed a second port for treatment of bleeding from an intercostal vein. No patient died in the perioperative period.

Postoperative and follow-up results in VATS group
After operation, 53 patients (98.1%) responded very well; in the remaining patient, one side continued wet, whereas the other became dry. At reevaluation, 27 patients (90% of the 30 patients with a follow-up longer than 6 months) had dry limbs, 1 showed increasing sweat production but was improved compared with the preoperative condition, 1 had recurrence of axillary hyperhidrosis, and 1 patient was wet unilaterally, not responding to the operation. Twenty-four (80%) of these 30 patients were satisfied, 5 (16.7%) reported partial satisfaction, and 1 patient was not satisfied with the outcome.

Complications and side effects
Twelve patients (3.8%) in the CTS group and 1 VATS patient (1.9%) (bilaterally) had a pneumothorax of more than 3 cm on the postoperative chest radiograph. Of these 13 patients, 7 (6, CTS group, and 1, VATS group) required chest tube drainage. As mentioned earlier, we had to open the chest of 1 patient in the CTS group in whom intercostal bleeding developed intraoperatively that could not be treated endoscopically. Pleural effusion was observed in 6 patients (1.9%) in the CTS group and 1 patient (1.9%) in the VATS group.

Regarding side effects, 66.8% of patients in the CTS group and 69% in the VATS group reported compensatory sweating, located mainly in the feet, face, axillae, back, and breast. Gustatory sweating was observed in 50.4% and 27.6% of patients in the CTS and VATS groups, respectively.

A significant difference in the incidence of permanent Horner’s syndrome was observed between the two groups. In the period when CTS procedures were being performed, Horner’s syndrome occurred in 12 patients (4.6%) of 262 patients (2.2% of the 558 procedures), ptosis combined with miosis in 4 patients (1.5%; 0.7% of the 558 procedures), and ptosis alone in 6 (2.3%; 1.1% of the 558 procedures). There was increased susceptibility to nasal obstruction or vasomotor rhinitis in 26 patients (9.9%). These complications (complete and partial Horner’s syndrome, ptosis, and nasal obstruction) occurred throughout the whole CTS period; they were not limited to the early years. Since the introduction of the video-assisted thoracoscopic procedure, we have not seen nor have patients reported complete or incomplete Horner’s triad or rhinitis postoperatively. Results of the between-group statistical analysis are highlighted in Table 2.

	Comment

Top Abstract Introduction Material and methods Results Comment References

Several groups have reported numerous advantages of thoracoscopic sympathicotomy [15–17] and sympathicotomy [6–8, 18] compared with open procedures. To our knowledge, however, there is only one randomized study comparing open and endoscopic sympathicotomy [19]. Its authors favor the open approach with respect to anesthesia time and postoperative chest pain but did not fully exploit the advantages of the thoracoscopic procedure. In our opinion, a very complicated resection procedure with three broad ports was performed, and chest tubes were used [19].

On the basis of large series reported in the literature, we gather that the success rates of sympathetic chain resection [16, 17] are comparable to the results of sympathicotomy by coagulation. Consequently, sympathectomy seems to represent overtreatment that does not further improve the outcome and should be discarded in favor of the less invasive, simpler, and more efficient (less expensive) procedure of sympathicotomy.

Reevaluating the patients operated on in our institution to 1991, we observed Horner’s syndrome in 12 of 270 patients [13] and rhinitis in about 10%. All of these patients had operation under direct optical viewing. Because the early period had no increased incidence of Horner’s syndrome, the occurrence of this complication is not due to the learning curve.

Inspired by the laparoscopic techniques introduced in our department, we have routinely used video assistance for thoracoscopic sympathicotomy since 1991. Video assistance clearly improves visualization, orientation, and endothoracic exposure.

Horner’s syndrome usually occurs when the T1 ganglion is included in the severance or sympathicotomy [10, 18] or when it is severed unintentionally because of poor visibility and tissue damage caused by diathermy as a result of a lack of optical control. This did happen in our CTS group. The magnification and the contrast quality attained with the videoscope allows more selective division of the interganglionic fibers between T1 and T2 and thereby helps avoid severance of the stellate ganglion. We observed no case of Horner’s syndrome in more than 100 video-assisted sympathicotomies we have done to date.

We noticed similar results with respect to rhinitis, another symptom of a stellate ganglion lesion. Missing the correct level and severing the wrong ganglia is one cause of an unsuccessful outcome or a higher incidence of Horner’s syndrome and vasomotor rhinitis. Results from previous studies confirm our findings; Shachor and coworkers [11] credited the lower incidence of Horner’s syndrome to the clarity with which the stellate ganglion is identified by the video system.

In our experience, video-assisted endoscopy also provides better visualization of the fibers of Kuntz [14] and other inconsistently present accessory fibers parallel to the sympathetic chain. Therefore, this technique can be expected to increase the safety of division, especially for surgeons less experienced in the treatment of hyperhidrosis. The advantages of the video-assisted procedure in teaching residents are evident.

According to a previous report [20], the incidence and the degree of compensatory sweating appear to depend mainly on the extent of severance of the sympathetic chain. The extent of sympathicotomy was the same in all patients in our study, and thus the incidence of compensatory sweating was similar in both groups. The high overall rate of compensatory sweating is comparable to most of the previously reported observations. In the majority of patients, compensatory sweating was only a minor inconvenience compared with the preoperative problem of hyperhidrosis unless this sweating persisted throughout follow-up. In some patients, compensatory or gustatory sweating prevented full patient satisfaction, though it did not cause fundamental disagreement with the operative result. To date, we have no explanation for the significantly lower rate of gustatory sweating in the VATS group.

On the basis of our findings, we conclude that video assistance increases surgical safety and the ease of thoracoscopic sympathicotomy without reducing the efficacy of the procedure. We strongly recommend the use of video endoscopy in the surgical treatment of upper limb hyperhidrosis, especially because video equipment is readily available in nearly all departments of general surgery.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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