Ann Thorac Surg 2001;72:895-898
© 2001 The Society of Thoracic Surgeons
Original article: general thoracic
Video-assisted thoracoscopic "resympathicotomy" for palmar hyperhidrosis: analysis of 42 cases
Torng-Sen Lin, MDa
a Division of General Thoracic Surgery, Changhua Christian Hospital, Chung Shan Medical and Dental College, Taichung, Taiwan
Accepted for publication May 9, 2001.
Address reprint requests to Dr Lin, No. 135, Nanh-siao St, Changhua city, Taiwan, Republic of China
e-mail: lin8065{at}ms14.hinet.net
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Abstract
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Background. There are rare reports of video-assisted thoracoscopic resympathicotomy for patients with palmar hyperhidrosis. I present our experience in treating a persistent or recurrent palmar hyperhidrosis after primary endoscopic sympathectomy or sympathicotomy and discuss the perioperative management.
Methods. We reoperated on 42 patients using a technique of video-assisted thoracoscopic resympathicotomy. All patients were placed in a semi-sitting position under single- or double-lumen intubated anesthesia. An 8-mm, 0° thoracoscope was used to interrupt the nerve conduction to the palms from the T2 and T3 ganglia, through one or two 0.8-cm subaxillary incisions.
Results. The reasons for failure of endoscopic sympathectomy or sympathicotomy in 26 patients included pleural adhesion (15 of 26, 57.7%), incorrect identification of T2 ganglion (3 of 26, 11.5%), vessel overriding or close to sympathetic nerve (3 of 26, 11.5%), incomplete interruption of sympathetic nerve (2 of 26, 7.7%), medially located sympathetic nerve (2 of 26, 7.7%), and aberrant venous arch (1 of 26, 3.8%). The causes of recurrent palmar hyperhidrosis after primary transthoracic endoscopic sympathicotomy or sympathectomy (TES) in 16 patients included a possible effect of T3 ganglion (8 of 16, 50%), Kuntz fiber (3 of 16, 18.8%), nerve regeneration (3 of 16, 18.8%), and incomplete interruption of T2 ganglion (2 of 16, 12.5%). Surgical complications included pneumothorax (1 patient, 2.4%), hemothorax (1 patient, 2.4%), and compensatory sweating (36 patients, 86%). All patients had obtained successful bilateral sympathectomies and had satisfactory results after a mean of 32.1 months of follow-up.
Conclusions. Video-assisted thoracoscopic resympathicotomy is an effective and safe method for a previously unsuccessful sympathectomy or recurrent palmar hyperhidrosis if the surgeon acknowledges possible anatomic variations and can overcome the problems related to pleural adhesions.
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Introduction
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Palmar hyperhidrosis (PH) is a common functional disorder that may pose serious psychologic, social, occupational, and learning problems for many students and adults. The existing nonoperative therapeutic options seldom give sufficient relief, and effects are usually transient. Currently, transthoracic endoscopic sympathicotomy, defined as division of the upper and lower portions of the sympathetic trunk, and sympathectomy, defined as ablation of the ganglion or resection of one segment of the sympathetic trunk, are the treatments of choice for palmar hyperhidrosis [1–8]. However, successful bilateral sympathicotomies or sympathectomies for PH are reported in about 93.6% to 99% of patients [4, 8, 9]. The reported primary failure of first-time sympathectomy for PH or recurrence rate is 0% to 5% [1, 4, 8, 10, 11]. Therefore, many people need video-assisted thoracoscopic resympathicotomy (VATR) to resolve profuse sweating of the hands after primary sympathectomy transthoracic endoscopic sympathicotomy or sympathectomy (TES).
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Patients and methods
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From July 1995 to August 1999, we treated 42 patients with video-assisted thoracoscopic resympathicotomy. There were 17 males and 25 females, with a mean age of 25.1 years (range 18 to 50 years). Most patients were referred from other hospitals where patients received unsuccessful TES for PH. All patients were placed in a semi-sitting position with abduction of both arms. We used single-lumen intubated anesthesia for the first 10 patients undergoing VATR, but changed to double-lumen intubated anesthesia for subsequent patients undergoing VATR. Throughout the procedure, patients were ventilated with 100% oxygen and were anesthetized with propofol (Diprivan). Peripheral arterial hemoglobin saturation (SaO2) was monitored with a pulse oximeter, with palmar temperature monitoring. A 0.8-cm incision in the third intercostal space was made bilaterally below each axilla, just posterior to the pectoralis major muscle (or along the previous surgical incision). The ipsilateral endotracheal tube was clamped by the anesthesiologist to deflate the operative lung, then the pleural cavity was entered using mosquito forceps to avoid damaging the lung parenchyma. A 8-mm, 0° thoracoscope (Karl Storz Co, Tuttlingen, Germany) was introduced into the pleural cavity through an obtuse head trocar. The upper sympathetic nerve was initially obscured by lung parenchyma owing to pleural adhesions, but it was gradually brought into view after meticulous lysis. Interruption of nerve conduction to the palms from the T2, T3 ganglia and any Kuntz fibers was performed with conventional electrocautery (Fig 1), but we never resected a sympathetic trunk. Sometimes, creation of a second 1-cm incision in the fourth or fifth intercostal space along the anterior axillary line was helpful to facilitate lysis of adhesions. When the temperature of both hands had elevated 0.5°C to 1°C, sympathicotomy was considered adequate.
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Fig 1. Appropriate T2 and T3 sympathicotomies at the second, third, and fourth rib beds for patients with recurrent palmar hyperhidrosis.
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After adequate sympathicotomies, the lung was reinflated under visual control. It was important to have the anesthesiologist exert continuous positive pressure for a few seconds before the skin was closed, in order to prevent pneumothorax and possible incomplete expansion of the lung. No thoracic drains were needed unless pneumothorax or hemothorax was noted. The surgical wound was closed with subcutaneous suture for cosmetic considerations. A chest radiograph was checked postoperatively to rule out hemopneumothorax or incomplete lung expansion. Most patients were discharged on the first postoperative day, and returned to their ordinary activities within 1 week.
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Results
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Of the 42 patients, 22 had unilateral sweating of the hands and 20 patients had bilateral sweating. Twenty-six patients underwent VATR due to a previously unsuccessful TES, and 16 patients for recurrent palmar hyperhidrosis. The reasons for technique failure after primary TES included pleural adhesion (15 of 26, 57.7%), incorrect identification of T2 ganglion (3 of 26, 11.5%), a vessel overriding or close to a sympathetic nerve (3 of 26, 11.5%), incomplete interruption of sympathetic nerve (2 of 26, 7.7%) or medially located sympathetic nerve (2 of 26, 7.7%), and aberrant venous arch drainage into the superior vena cava (1 of 26, 3.8%) (Table 1). The causes of recurrent palmar hyperhidrosis after primary TES included possible effect of a T3 ganglion (8 of 16, 50%), Kuntz fiber (3 of 16, 18.8%), nerve regeneration (3 of 16, 18.8%), and incomplete interruption of T2 ganglion (2 of 16, 12.5%). The findings during operation included diffuse pleural adhesions (13 of 42, 30.1%), adhesion bands (2 of 42, 4.8%), vessels overriding or close to sympathetic chains (3 of 42, 7.2%), obscuration of upper sympathetic trunk by adipose tissue (1 of 42, 2.4%), medially located upper sympathetic trunk (2 of 42, 4.8%), aberrant great venous vessel drainage to superior vena cava (1 of 42, 2.4%), congenital bullae (1 of 42, 2.4%), and hypertension with intrathoracic vessel engorgement (1 of 42, 2.4%) (Table 2). Surgical complications included pneumothorax (1 patient, 2.4%), hemothorax (1 patient, 2.4%), and compensatory sweating (36 patients, 86%). Neither permanent nor transient Horner’s syndrome occurred in any patient. There was no surgical mortality. The mean operation time was 28 minutes (range 18 to 42 minutes). The duration of operation was mainly associated with the degree of pleural adhesions. Successful sympathicotomies were achieved in all patients. Most patients were discharged on the operative day. The mean follow-up time is 32.1 months (range 6 to 51 months). All patients have had satisfactory results (improvement of palmar hyperhidrosis), no recurrent symptoms, and no troublesome compensatory sweating.
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Comment
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TES is the best treatment for palmar hyperhidrosis [1–8]. Patients who undergo an unsuccessful TES may suffer from dryness of one hand and persistent hyperhidrosis of the other one. This is embarrassing for the patient, and resolution of either a previous failed TES or recurrent palmar hyperhidrosis is important. Although TES at T2-4 level is an easy, safe, and effective procedure for treating PH, the immediate failure rate postsympathectomy is 2% for open and 1% for endoscopic procedure [10]. Drott and associates reported that primary failure occurred in 1.9% of cases, and 2% developed recurrent symptoms (total of 1,163 patients) during a mean of 31 months of follow-up [4]. Many explanations for these failures have been given. An anatomic variation in the sympathetic chain and failure of surgical technique are the most important factors. Previously reported reasons for failure of a primary TES or recurrent symptoms include severe pleural adhesions [6, 8, 9], existence of the nerve of Kuntz [10–14], nerve regeneration [8, 10–13], anatomic variation of the sympathetic chain [8, 11], and incomplete interruption of sympathetic chain [11]. Maintenance of adequate ventilation, oxygenation via laryngeal mask, and single- or double-lumen endotracheal tube have been advocated by anesthesiologists for the management of patients receiving the first TES [15–17]. We adopted single-lumen endotracheal anesthesia for the first 10 patients and successfully accomplished the procedures. The incidence of pleural adhesion was about 1.6% to 6.4% [6, 8, 9] in patients without previous thoracic disease undergoing TES. The incidence of pleural adhesions was higher in patients who underwent a previously unsuccessful sympathicotomy or sympathectomy. Pleural adhesions contributed to 58% of cases of technique failure after primary surgery, and we often noted persistent function of the T2 ganglion after our meticulous pleural lysis in these patients. The pleural adhesions may be too diffuse and severe to overcome under a single-lumen intubated anesthesia. Therefore, we recommend a semi-sitting position with double-lumen intubated anesthesia for patients undergoing resympathicotomy or resympathectomy. Single-lumen intubated anesthesia is still suggested for patients undergoing the first sympathicotomy or sympathectomy.
Chiou and colleagues, from studies of 17 adult cadavers, classified the relationship between the T2 ganglion and the third rib into three types, and found the T2 ganglion at the second intercostal space near the upper border of the third rib in most cases [18]. According to the aforementioned information, the T3 ganglion is located between the third and fourth rib beds. Although the innervation of the upper extremities is from the T2 to T9, the T2 ganglion is the key one for hyperhidrosis of the hands [7, 8, 19]. Basically, we only perform the T2 sympathicotomy at the second and third rib beds in treating patients with palmar hyperhidrosis undergoing the first operation. T3 sympathicotomy at the third and fourth rib beds was reserved for patients with recurrent palmar hyperhidrosis due to a possible T3 effect even after complete T2 sympathicotomy. The effect of the T3 ganglion is suggested by the following: a complete T2 sympathicotomies at the second and third ribs was performed, and no visible Kuntz fiber near the T2 or T3 ganglia. For patients with recurrent palmar hyperhidrosis, we perform interruption of the conduction impulse from the T2 and T3 ganglion to the palms by sympathicotomies at the second, third, and fourth rib beds instead of ganglionectomy or resection of sympathetic trunk. Approximately 10% of persons have extraneural pathway lateral and parallel to the main sympathetic chain (the nerve of Kuntz), through which sympathetic nerve fibers reach the brachial plexus without passing through the sympathetic trunk, causing persistent sweating of the hands [11, 12, 14]. Hsu and colleagues suggest that it is important to ablate the T2, T3 ganglia and possible Kuntz fibers in treating patients with recurrent palmar hyperhidrosis or a previously unsuccessful TES [11]. Regeneration of preganglionic fiber is another explanation for the return of hyperhidrosis of the hands [11, 13, 14]. Therefore, it is imperative to keep at least 2 to 3 mm between ends of the interrupted sympathetic trunks to reduce the chance of nerve regeneration [8]. We routinely sent the regenerated nerve and fibrotic tissue between the divided sympathetic trunk in front of the rib beds for pathological examination, if we suspected that nerve regeneration was the cause of recurrent palmar hyperhidrosis after TES.
One of our patients underwent VATR due to the existence of an aberrant venous arch draining into the superior vena cava, which covered the upper sympathetic nerve. In this situation, T2 sympathicotomy could be accomplished if the surgeon identified the upper sympathetic chain correctly beneath this unusual vein just lateral to the trachea.
Compensatory hyperhidrosis was the most common complication in previous studies [1–8], and compensatory sweating has developed in 45% to 98.6% of patients [1, 5–8]. In our study, 86% developed compensatory hyperhidrosis of the trunk and lower limbs after the VATR, with the discomfort being greatest during the first summer after operation. The symptom was well tolerated with time. Despite its high incidence, there is no effective way to avoid it. It seems there is a correlation between the extent of sympathicotomy or sympathectomy and the severity of compensatory hyperhidrosis [7]. Basically, most compensatory sweating after T2 and T3 sympathicotomies is mild or moderate. None of the 42 patients was bothered by postoperative compensatory sweating and all had improvement of palmar hyperhidrosis.
Video-assisted thoracoscopic T2 and T3 sympathicotomy is a simple, safe, and effective method to treat a persistent or recurrent palmar hyperhidrosis after primary endoscopic sympathicotomy or sympathectomy. Both semi-sitting position and double-lumen endotracheal anesthesia are recommended during operation. A variety of possible problems during operation can be resolved if the surgeons acknowledge the anatomic variation and are capable of performing lysis of pleural adhesions.
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Acknowledgments
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I appreciate Dr Tom Karl’s language editing.
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References
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-
Herbst F., Plas E.G., Fugger R., Fritsch A. Endoscopic thoracic sympathectomy for primary hyperhidrosis of the upper limbs. A critical analysis and long-term results of 480 operations. Ann Surg 1994;220:86-90.[Medline]
-
Hashimonai M., Kopelman D., Kein O., Schein M. Upper thoracic sympathectomy for primary palmar hyperhidrosis: long-term follow-up. Br J Surg 1992;79:268-271.[Medline]
-
Shachor D., Jedeikin R., Olsfanger D., Bendahan J., Sivak G., Freund U. Endoscopic transthoracic sympathectomy in the treatment of primary hyperhidrosis. A review of 290 pathectomies. Arch Surg 1994;129:241-244.[Abstract]
-
Drott C., Claes G. Hyperhidrosis treated by thoracoscopic sympathicotomy. Cardiovasc Surg 1996;4:788-791.[Medline]
-
Lai Y.T., Yang L.H., Chio C.C., Chen H.H. Complications in patients with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy. Neurosurgery 1997;41:110-114.[Medline]
-
Lin C.C., Mo L.R. Experience in thoracoscopic sympathectomy for hyperhidrosis with concomitant pleural adhesion. Surg Laparosc 1996;6:258-261.
-
Kao M.C., Lin J.Y., Chen Y.L., Hsieh C.S., Cheng L.C., Huang S.J. Minimal invasive surgery: video endoscopic thoracic sympathectomy for palmar hyperhidrosis. Ann Acad Med Singapore 1996;25:673-678.[Medline]
-
Lin T.S. Transthoracic endoscopic sympathectomy in the treatment of palmar hyperhidrosis: with special emphasis on perioperative management (1360 cases analysis). Surg Neurol 1999;52:453-457.[Medline]
-
Wong C.W. Transthoracic video endoscopic electrocautery of sympathetic ganglia for hyperhidrosis palmaris: special reference to localization of the first and second ribs. Surg Neurol 1997;47:224-230.[Medline]
-
Orteu C.H., Mcgregor J.M., Almeyda J.R., Rustin M.H.A. Recurrence of hyperhidrosis after endoscopic transthoracic sympathectomy: case report and review of the literature. Clin Exp Dermatol 1995;20:230-233.[Medline]
-
Hsu C.P., Chen C.Y., Hsia J.Y., Shai S.E. Resympathectomy for palmar and axillary hyperhidrosis. Br J Surg 1998;85:1504-1505.[Medline]
-
Kuntz A. Distribution of the sympathetic rami to the brachial plexus. Arch Surg 1927;15:871-877.[Abstract/Free Full Text]
-
Singh B., Moodley J., Haffejee A.A., Ramdial P.K., Robbs J.V., Rajaruthnam P. Resympathectomy for sympathetic regeneration. Surg Laparosc endosc 1998;8:257-260.[Medline]
-
van Rhede van der Kloot E.J.H., Jorning P.J.G. Resympathectomy of the upper extremity. Br J Surg 1990;77:1043-1045.[Medline]
-
Hsieh Y.J., Chen C.M., Lin H.Y., Young T.F. Experience of anesthesia during transthoracic endoscopic sympathectomy for palmar hyperhidrosis: comparison between double-lumen endobronchial tube ventilation and laryngeal mask ventilation?. Acta Anaesthesiol Sin 1994;32:13-20.[Medline]
-
Lee L.S., Ng S.M., Lin C.C. Single-lumen endotracheal intubated anesthesia for thoracoscopic sympathectomy-experience of 719 cases. Eur J Surg 1994;572:27-31.
-
Lin T.S. Transthoracic endoscopic sympathectomy for palmar hyperhidrosis in children and adolescents (350 cases analysis). Laparoendosc Ad Surg Techniques 1999;9:327-330.
-
Chiou T.S.M., Liao K.K. Orientation landmarks of endoscopic transaxillary T-2 sympathectomy for palmar hyperhidrosis. J Neurosurg 1996;85:310-315.[Medline]
-
Kao M.C., Chen Y.L., Lin J.Y., Hsieh C.S., Tsai J.C. Endoscopic sympathectomy treatment for craniofacial hyperhidrosis. Arch Surg 1996;131:1091-1096.[Abstract]
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Abstract
Introduction
