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Ann Thorac Surg 2007;83:1850-1853
© 2007 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Outpatient Microthoracoscopic Sympathectomy for Palmar Hyperhidrosis

Section of General Thoracic Surgery, Department of General Surgery, Emory University School of Medicine, Atlanta, Georgia

Accepted for publication November 9, 2006.

^_* Address correspondence to Dr Miller, Section of General Thoracic Surgery, Emory University Clinic, 1365 Clifton Rd NE, Atlanta, GA 30322 (Email: daniel.miller{at}emoryhealthcare.org).

Presented at the Fifty-second Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 10–12, 2005.

	Abstract

Top Abstract Introduction Material and Methods Results Comment Discussion References

 
Background: Sympathectomy for palmar hyperhidrosis has been performed for more than 80 years with excellent long-term results. However, several issues are still unresolved: best surgical approach, which level and the number of levels of the sympathetic chain should be divided and the safety of an outpatient procedure.

Methods: We reviewed the records of 205 patients who underwent sympathectomy for hyperhidrosis at our institution from April 2002 through March 2005. Fifty consecutive patients (24%) underwent an outpatient microthoracoscopic sympathectomy of a single level (T2) for palmar hyperhidrosis. Operative reports, medical records, and clinical charts were reviewed to determine the success of a single level sympathectomy, the incidence of postoperative compensatory hyperhidrosis, and the safety of an outpatient sympathectomy procedure.

Results: There were 41 women (82%) and 9 men. Median age was 22 years (range, 14 to 62). The surgical technique consisted of single-lumen endotracheal tube general anesthesia, single bilateral access incisions (4 mm), 3-mm, 30-degree thoracoscope, temporary CO₂ insufflation, electrocautery nerve division, and no chest drainage. Median operating time was 22 minutes (range, 14 to 50). Sympathectomy consisted of dividing the sympathetic chain at the T2 level and any accessory nerves present. Anatomically, 19 patients (38%) had accessory nerves, right sided in 11, left sided in 5, and bilateral in 3. Two patients (4%) had a chest tube (10F) placed at the time of sympathectomy because of required lysis of apical pleural adhesions. No patient had postoperative bleeding or a wound infection. All patients were discharged the day of surgery. Median follow-up was 15 months (range, 1 to 36). Compensatory hyperhidrosis developed in 6 patients (12%), in 4 with rest and in 2 during exercise, all within 4 weeks. Successful sympathectomy was achieved in 99% of palmar surfaces without recurrence. A single patient experienced persistent sweating of the left hand. Reoperation was successful by dividing level T3.

Conclusions: Single level (T2) microthoracoscopic sympathectomy for palmar hyperhidrosis has a high success rate with a low incidence of compensatory hyperhidrosis. This minimally invasive procedure can be performed safely as an outpatient and should be the preferred treatment for medical refractory palmar hyperhidrosis.

	Introduction

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Excessive sweating is a psychosocial nightmare. Between 0.5% and 2% of the population suffer from excessive sweating or hyperhidrosis [1]. The primary cause is unknown, but the majority of cases are thought to be caused by overstimulation of the sympathetic nervous system. Primary hyperhidrosis affects localized areas of the body such as the hands, feet, axilla, and face; palmar hyperhidrosis (PH) is the most common.

Once medical therapy becomes ineffective, sympathectomy should be considered. Video-assisted thoracic surgery (VATS) has become the most popular approach to sympathectomy, but this approach is still evolving in areas such as single lung anesthesia techniques, prevention of postoperative pneumothorax, and number of access incisions required.

Even though a sympathectomy is extremely successful in eliminating hyperhidrosis, postoperatively a significant number of patients may develop unwanted excessive sweating in other regions of body [2–4]. This condition is referred to as compensatory hyperhidrosis (CH). Because of this side effect, a number of patients do not undergo a sympathectomy for hyperhidrosis. Currently, controversy exists as to which level and the number of levels the sympathetic chain that should be divided to ensure the greatest success with the least risk of compensatory hyperhidrosis. The purpose of this study is to review the results of 50 consecutive patients who underwent a single level (T2) outpatient sympathectomy for primary palmar hyperhidrosis in regard to success of a T2 sympathectomy for PH, to determine the incidence of CH after a T2 sympathectomy, and to evaluate if this procedure can be performed safely on an outpatient basis.

	Material and Methods

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We retrospectively reviewed the medical records of all patients who underwent a sympathectomy for hyperhidrosis at our institution from April 2002 through March 2005. Two hundred and five patients were identified; 50 patients (24%) underwent a single level T2 outpatient sympathectomy for palmar hyperhidrosis. The medical record, operative report, anesthesia record, and clinic charts were examined for each patient. Follow-up information was obtained from the medical records and patient’s clinic chart. A postsympathectomy questionnaire was completed by each patient at the time of their first postoperative visit and at their last follow-up visit. Specific questions detailed the patient’s incidence of CH, other side effects of the procedure, postoperative pain, and satisfaction of the procedure. This study was approved by the Emory University School of Medicine’s Institution Review Board (IRB 05-0234) on February 2, 2005. The individual patient consents were waived for this retrospective study.

Clinical Findings
Indication for sympathectomy in the 205 patients was palmar hyperhidrosis only in 31, palmar and plantar in 85, palmar and axillary in 41, palmar, axillary, and plantar in 29, axillary only in 13, and facial in 6. Level of sympathectomy was T2 only in 56, T2- T3 in 41, T2 to T4 in 56, and T3 to T4 in 13 and varied on the basis of the primary indications for surgery and the discretion of the surgeon.

Fifty consecutive patients underwent a single T2 outpatient bilateral thoracoscopic sympathectomy for PH and form the basis for this study. There were 41 women (82%) and 9 men. Median age was 22 years (range, 14 to 62). The primary indication in all 50 patients was palmar hyperhidrosis of unknown etiology. Plantar hyperhidrosis was also present in 32 patients (64%). Medical treatment had been exhausted before patients being considered for sympathectomy. Previous medical treatment consisted of topical agents, most commonly aluminum chloride in 50 patients (100%), oral medications (robinul, probathine, and or beta blockers) in 40 (80%), iontophoresis in 22 (44%), palmar botox injections in 8 (16%), and other treatments in 15 (30%). Median time interval from initiation of medical treatment to sympathectomy was 48 months (range, 12 to 480). Twelve patients (24%) had a first- or second-degree relative with a history of PH.

Surgical Technique
Microscopic thoracoscopic sympathectomy (MTS) was performed on a patient as an outpatient within our hospital’s main operating room or in our ambulatory surgical center. The patients are placed in a supine position. General anesthesia is initiated with a single-lumen endotracheal tube. After the patient is asleep the arms are extended to 90 degrees. Excessive abduction of the upper extremities is avoided to prevent injury to the brachial plexus. Temperature probes are placed on each index finger. Each axilla is prepared in standard fashion.

Attention is first directed to the right side. A single 4-mm incision is made vertically over the fourth rib along the mid-axillary line. Using a mosquito clamp, the chest cavity is entered over the fourth rib during suspension of ventilation. During continued ventilation suspension, a 3-mm, 30-degree rigid thoracoscope (Karl Storz, Munich, Germany) is placed. Along side the thoracoscope a standard laparoscopic Varess needle (Ethicon, Cincinnati, Ohio) is also placed. After the two instruments are placed without difficulty, ventilation is resumed with a decrease tidal volume of 250 cc for women and 300 cc for men. Temporary CO₂ insufflation is carried out to 10 mm Hg for approximately 60 to 90 seconds to allow for partial collapse of the lung. The Varess needle is removed, and through the same incision, a 2-mm long electrocautery is placed. A detailed examination is carried out of the apical and posterior chest to accurately identify the anatomy of the sympathetic chain and its accessory nerves. Before division of the nerve, a finger temperature is taken for baseline measurement. The sympathetic chain is then divided over the second rib to complete a T2 sympathectomy. Also, all accessory nerves are divided with electrocautery. The cauterized ends of the nerves are separated from each other to allow at least a 1.0 to 1.5 cm gap to dimish the chance of regrowth and possible recurrence of PH.

After complete division of the nerve, a posttreatment temperature is taken at 5 minutes. The sympathectomy site is examined for hemostasis. A 2-mm suction catheter is then placed to the apex of the chest under direct visualization. The external end of the catheter is placed in a basin of sterile water to create a water seal. Utilizing sterile water immersion of the catheter, positive pressure ventilation to 40 mm Hg, and suctioning the pneumothorax is evacuated. After the pneumothorax is evacuated, the catheter is removed. The skin is reapproximated with a Dermabond adhesive (Ethicon Inc, Somerville, NJ). The left side is completed in similar fashion. Marcaine, 15 cc of 0.25%, is injected into each incision before making the incision and at the time of closure. Also, 30 mg of ketorolac is given intravenously before making the first incision. Sterile dressings are applied, and the patient is taken to the recovery room.

In the recovery room, an upright chest roentgenogram is obtained approximately 30 minutes after completion of the procedure. If the chest roentgenogram is satisfactory and the patient is having minimal discomfort, the patient is dismissed from the hospital. The majority of patients return to work within 3 to 5 days and to the clinic within 3 to 4 weeks for routine postoperative visit.

	Results

Top Abstract Introduction Material and Methods Results Comment Discussion References

 
Sympathectomy was completed in all patients bilaterally with division of the nerve at the single level (T2). Anatomically, 19 patients (38%) had accessory nerves, right sided in 11, left sided in 5, and bilateral in 3. All identified accessory nerves were divided to complete the sympathectomy. Median operating time was 22 minutes (range, 14 to 50). Two patients (4%) had a chest tube (10F) placed at the time of MTS because of extensive lysis of adhesions between the apex of the chest cavity and the lung. Both chest tubes were removed within 4 hours of placement. There were no operative deaths, and no patient had a postoperative complication such as infection, bleeding, or Horner’s syndrome. All patients were discharged the day of surgery. Median postoperative hospitalization was 95 minutes (range, 45 to 360).

Follow-up was complete in all 50 patients and ranged from 1 to 36 months (median, 15). Three patients (6%) complained of transient dysesthesia of the arm. Compensatory hyperhidrosis developed in 6 patients (12%), 4 at rest and 2 with exercise. Three of these patients had accessory nerves divided at the time of their T2 sympathectomy. Successful MTS was achieved in 99% of the palmar surfaces without recurrence. A single patient experienced recurrent sweating of the left hand within 1 week after MTS. Reoperation was performed 4 weeks after MTS through the old microincision. Level T3 of the sympathetic chain was divided. The patient had no accessory nerves identified at either procedure. The redo operative was successful. Associated plantar hyperhidrosis was reduced or eliminated in 32 patients (64%). Forty-nine of the patients (98%) were satisfied with their MTS. A single patient with significant CH stated that she had wished that she had not undergone the procedure.

	Comment

Top Abstract Introduction Material and Methods Results Comment Discussion References

 
The current era of sympathectomy has been explosive. The procedure has changed significantly. When we first started doing the procedure thoracoscopically more than 10 years ago, the patient would have a double-lumen endotracheal tube placed for single-lung anesthesia, full lateral decubitus positioning, multiple access incisions, complete removal of the sympathetic chain from T2 to T4, chest tubes, and hospital stay of 2 to 5 days. Our current thoracoscopic sympathectomy technique as described above is less involved, safe, and extremely effective in the treatment of PH. As with any new procedure, there is a learning curve. The hardest part of the MTS procedure is using multiple instruments through a single access incision. With time, however, the single incision technique has become second nature. Also, because a trocar is not required and the instruments are smaller (2 to 3 mm in diameter), there is less chance of torque injury to the rib’s neurovascular bundle, which could lead to prolonged pain at the access site. Positioning is also easier; with the patient lying in the supine position, there is no need to turn the patient, which prolongs anesthesia time. Almost 50% of cases are performed in less than 20 minutes.

The biggest leap of faith for us was to perform the procedure on an outpatient basis. Traditionally, we would observe the patient overnight in the hospital because of the risk of pneumothorax. Approximately 10% to 15% of patients have a small apical pneumothorax on their postoperative dismissal film that usually resolves in 1 to 3 days. The reason for quick resolution of the pneumothorax and increased comfort level for same-day dismissal of the patients has been because of the use of CO₂ insufflation during the procedure. Originally, we used a double-lumen endotracheal tube for single-lung anesthesia to perform the sympathectomy. Because of the total lung collapse and ateletacsis caused by the double-lumen endotracheal tube, several patients had to be observed overnight because of a persistent pneumothorax. The reason for switching to a single-lumen endotracheal tube and CO₂ insufflation was because our ambulatory surgery center anesthesiologists were uncomfortable with placement of double-lumen endotracheal tubes, thus requiring us to modify our anesthesia technique. Since introducing CO₂ insufflation, we have not had a single patient who required treatment for a pneumothorax. Temporary CO₂ insufflation causes only partial collapse of the upper lobe, which is much easier to evacuate pneumothorax and achieve total reexpansion of the lung. With an incredibly dedicated team of surgeons, nurses, and anesthesiologists, we have been able to perform MTS with no operative mortality or morbidity and minimal discomfort. The patients have been extremely pleased with the MTS procedure from a recovery standpoint, with the majority of patients returning to normal activities within 3 to 5 days.

Sympathectomy for PH is extremely successful. However, the incidence of CH is disturbing. The incidence of CH ranges from 4% to 99% depending on the level of sympathectomy and on the multitude of levels treated [1–4]. Early in our experience, we performed three-level sympathectomies (T2 to T4, complete removal of chain) with excellent results for PH, but our CH rate was 90%. Over the last 3 years, we have tried several different sympathectomy levels (isolated division) of T2 to T4, T2 to T3, and now have switched to a single-level sympathectomy at the T2 level. Controversy exists as to which level and the number of levels that should be divided. Hsu and colleagues [5] showed that a significant reduction in the incidence of CH occurred switching from a T2 to T4 to a T2 sympathectomy. Compensatory hyperhidrosis was reduced from 64% to 25%, respectively. In this present study, we achieved a significant reduction in our CH to a rate of 12%; however, the risk continues. Unfortunately, our only dissatisfied patient had significant CH, even though she had complete resolution of palmar and plantar hyperhidrosis. We were unable to determine the incidence of CH and the long-term success in all of our patients undergoing sympathectomy during this period because of the variability of primary indications for the procedure and the different levels treated. Therefore, in this study, we concentrated on the 50 consecutive patients who underwent the same procedure (T2 sympathectomy) and for the same primary indication of PH.

The mechanism of CH is related to excessive rebound thermoregulatory function of the remaining sweat glands after the decrease of the function of a large number of sweat glands [6]. Treatment of CH is usually unsatisfactory. A small number of patients may respond to the anticholinergic agents (Robinul) for CH, but the benefits are usually short lived. Telaranta [7] claims that CH could be treated by reconstructive surgery of the sympathetic trunk using the sural nerve. The results of this procedure is in question [7].

The best way to prevent CH is not to cause it. It very important that conservative treatment be maximized before sympathectomy. There is a small percentage of patients who will not require a sympathectomy because of successful medical treatment. The majority of these treatments, however, are cumbersome, expensive, and painful. After a prolonged period, the majority of these treatment modalities become less effective because medical tolerance develops.

One potential way to determine if CH may be a problem postoperatively is to first do a temporary block of the nerve. The most common method of doing a "temporary sympathectomy" is to place several clips on the nerve at the time of planned sympathectomy. Several authors have recommended this procedure because if a patient has CH after the sympathectomy, the clips can be removed, thus reversing the CH [8–10]. We have operated on several patients who have had clips placed by other surgeons. We were successful in removing the clips without transecting the nerve, but none of the patients had their CH corrected. More than likely, permanent damage to the nerve has occurred from the multiple clips that would not allow regrowth or acceptable signaling along its path. Another possibility is to do a temporary block of the nerve with a local anesthetic such as Marcaine. It would be possible to inject the nerve at the planned level of sympathectomy to simulate a complete sympathectomy, but the effects of the block would be temporary. If the patient experiences a good result from the block with palmar dryness and no CH, then they could return for a MTS. However, if the patient has significant CH, it will be temporary; usually less than a week after the local block, the patient will have avoided permanent CH. A pilot study is under way at our institution to test this hypothesis.

In closing, hyperhidrosis is psychologically debilitating. Our outpatient T2 MTS has been extremely successful and gratifying as a treatment option for these patients. Our work is not complete, however, until CH is better understood and eliminated. A multicenter, prospective trial is warranted to determine at which level and the number of levels at which sympathectomy should be performed for PH to achieve the greatest benefit with the least risk of CH. At the present time, we favor a T2 MTS for our patients with PH.

	Discussion

Top Abstract Introduction Material and Methods Results Comment Discussion References

 
DR ROBERT J. CERFOLIO (Birmingham, AL): Dan, fantastic results and a beautiful technical operation you showed us—you are to be congratulated. We will talk more about the probes and the small scope, the 30 degrees, lens. There are a million things to talk about technically, which we can discuss later, but for time’s sake, tell us more about putting Marcaine into the nerve to tell if the patient is going to have compensatory hyperhydrosis. You kind of threw that in there and tried to sneak it by us—is this done under one anesthetic, and if it is, how long do you wait, and, let’s be honest, are you sure it really works? Are you able to really accurately tell if someone is going to have significant hyperhydrosis just by injecting a little Marcaine in the nerve, waiting around in the operating room for a few minutes, watching the finger temperature change, and then deciding whether to cut the sympathetic chain or not?

DR MILLER: The temporary block is performed as a separate procedure. We have been focusing on our patients with palmar and axillary disease, because when I do their sympathectomy I am dividing the nerve at the T2 and T3 levels, which has a higher compensatory sweating rate of 35–40%. Technically, we make the same small incision but instead of cauterizing the nerve we place a 2 mm suction device and through the center of it we pass a long 22 gauge laparoscopic needle. We inject 2.5 cc of 0.25% cc Marcaine at each level and 1.0 cc at the accessory nerves. In the two patients that have a block, one had an excellent result, completely dry and no compensatory sweating; the block lasted for 5 days. The other patient had good results for 7 days except for groin sweating. The first patient had a sympathectomy performed 2 weeks after the block with no problems with complete resolution of the palmar and axillary hyperhidrosis and no compensatory sweating. The second patient did not undergo the sympathectomy because of the concern for extensive groin sweating. The idea for the block came from Dr Rick Feins. Performing a redo procedure has not been problematic. There have not been any adhesions between the lung and the pleural because electrocautery was not used.

DR CERFOLIO: I see, so it is a second operation. I think this is a great idea, ingenuous really. The concept is maybe only in its infancy, but the idea is great. The problem is you are talking about giving someone two anesthetics instead of one, which you sort of slipped by us in the talk, but still, in these young healthy patients, that should not be a big deal if they understand why you are doing it this way and the real problem that compensatory sweating causes and the poor treatment we have for it. Excellent presentation.

DR MILLER: The main reason patients avoid a sympathectomy is because of the risk of permanent compensatory hyperhidrosis. The removable clip procedure has not been as reliable for primary hyperhidrosis relief or reversibility. The temporary block may be the answer, but a multicenter study is warranted.

	References

Top Abstract Introduction Material and Methods Results Comment Discussion References

 

1. Hasmonai M, Assalia A, Kopelman D. Thoracoscopic sympathectomy for palmar hyperhidrosisAblate or resect?. Surg Endosc 2001;15:435-441.[Medline]
2. Andrews BT, Rennie JA. Predicting changes in the distribution of sweating following thoracoscopic sympathectomy Br J Surg 1997;84:1702-1704.[Medline]
3. Gossot D, Toledo L, Fritsch S, et al. Thoracoscopic sympathectomy for upper limb hyperhidrosis: looking for the right operation Ann Thorac Surg 1997;64:975-978.[Abstract/Free Full Text]
4. Kopelman D, Assalia A, Ehrenreich M, et al. The effect of upper dorsal thoracoscopic sympathectomy on the amount of total body perspiration Surg Today 2000;30:1089-1092.[Medline]
5. Hsu CP, Chen CY, Lin CT, et al. Video-assisted thoracoscopic T2 sympathectomy for hyperhidrosis palmaris J Am Coll Surg 1994;179:59-64.[Medline]
6. Adar R, Kurchin A, Zweig A, et al. Palmar hyperhidrosis and its surgical treatment: a report of 100 cases Ann Surg 1977;186:34-41.[Medline]
7. Telaranta T. Reversal surgery for reducing the side effects of ETSA case report. Ann Chir Gynaecol 2001;10:175-176.[Medline]
8. Lin CC, Mo LR, Lee LS, et al. Thoracoscopic T2 sympathetic block by clipping—a better and reversible operation for the treatment of hyperhidrosis palmaris: experience with 326 cases Eur J Surg 1998;580:13-16.
9. Choi BC, Lee YC, Sim SB. Treatment of palmar hyperhidrosis by endoscopic clipping of the upper part of the T4 sympathetic ganglion Clin Auton Res 2003;13:48-51.
10. Lim CC, Wu HH. Endoscopic T4-symapthetic block by clamping in treatment of hyperhidrosis palmaris et axillaries experiences of 165 cases Ann Chirurg Gynaecol 2001;90:167-189.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Daniel L. Miller Seth D. Force Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Miller, D. L. Articles by Force, S. D. Search for Related Content PubMed PubMed Citation Articles by Miller, D. L. Articles by Force, S. D. Related Collections Mediastinum