Interact CardioVasc Thorac Surg 2008;7:67-70. doi:10.1510/icvts.2007.162479
© 2008 European Association of Cardio-Thoracic Surgery
Institutional report - Thoracic general |
Bilateral thoracoscopic sympathectomy: results and long-term follow-up
Reubendra Jeganathan*,
Simon Jordan,
Mark Jones,
Stephen Grant,
Owen Diamond,
Kieran McManus,
Alastair Graham and
Jim McGuigan
Department of Thoracic Surgery, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK
Received 29 June 2007;
received in revised form 11 October 2007;
accepted 15 October 2007
 Presented at the 15th European Conference on General Thoracic Surgery, Leuven, Belgium, June 3–6, 2007.
*Corresponding author. Cardiothoracic Surgery, Ground Floor West Wing, Royal Victoria Hospital, Grovenor Road, Belfast BT12 6BA, Northern Ireland, UK. Tel.: +44-2890-632077/44-2890-632027; fax: +44-2890633937.
E-mail address: reubenj{at}hotmail.com (R. Jeganathan).
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Abstract
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The aim of this study is to evaluate the efficacy of bilateral thoracoscopic sympathectomy in alleviating symptoms and improving quality of life in patients with hyperhidrosis or facial blushing and to investigate the occurrence, severity and possible underlying factors to compensatory sweating after surgery. One hundred and sixty-three patients in a single institution underwent bilateral thoracoscopic sympathectomy with a mean follow-up period of 51 (5–140) months. Indications were for palmar hyperhidrosis (41%), axillary hyperhidrosis (17%), combined palmar and axillary hyperhidrosis (27%) and facial blushing±facial hyperhidrosis (15%). Success rates were palmar 98.5%, axillary 96.4%, palmar and axillary 97.7% and facial blushing±facial hyperhidrosis 84%. Compensatory sweating occurred in 77% of patients and its severity was related to the severity of the primary complaint. Recurrence rates were palmar 4.6%, axillary 7.4%, palmar and axillary 9.3% and facial blushing±facial hyperhidrosis 4.7% at a mean of 22 (3–72) months. An improvement in quality of life was seen in 85% and a diminution of quality of life was noted in 5% due to compensatory sweating. This large mature series demonstrates that bilateral thoracoscopic division of the sympathetic chain as opposed to resection can be performed effectively in patients with success rates higher than 90% and low recurrence rates.
Key Words: Sympathectomy; Thoracoscopic; Sympaticotomy
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1. Introduction
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Primary hyperhidrosis is an extremely disabling condition with an estimated prevalence of 1% in the western world [1]. It can be defined as sweating in excess of the body's homeostatic requirements. It most often affects the palms of the hands, the axillae, or the face and may be a severe professional, psychological, and social burden to many patients. Medical treatment is often frustrating, and the response is usually transient. Surgical therapy is effective and is based on interruption of transmission of impulses from sympathetic ganglia to the eccrine sweat glands.
Thoracoscopic sympathectomy was first described in 1942 by Hughes [2], and remained rare until the introduction of video-endoscopic techniques in the 1980s. Since then it has become the preferred method of treatment of primary hyperhidrosis of the palms, axillae, and face and more recently for facial blushing. Compensatory sweating is the most common side effect, and is believed to be due to a thermoregulatory mechanism. The reported frequencies vary considerably, with conflicting views to its severity and predisposition. The aim of this study is to evaluate the efficacy of this procedure, to provide long-term follow-up data and to investigate the occurrence, severity and underlying factors to compensatory sweating in one institution.
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2. Patients and methods
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The data of patients undergoing thoracoscopic sympathectomy between January 1994 and May 2006 were prospectively entered into the Thoracic Surgical Database at the Regional Thoracic Unit, Royal Victoria Hospital, Belfast. One hundred and sixty-three patients underwent synchronous bilateral thoracoscopic sympathectomy. All patients had failed to respond to adequate medical treatment and were referred for surgery.
2.1. Data collection
A thoracoscopic sympathectomy questionnaire was created to collect the relevant information. The majority of information was obtained from the in-house Thoracic Surgical Database, which included patient demographics, presenting complaint, surgical details, early complications and results. Out of hospital data including long-term results, recurrence, late complications and changes to quality of life were obtained via telephone enquiry.
Our institution defined the severity of hyperhidrosis as follows: mild hyperhidrosis as patients who were aware of their increase in sweating and sought medical treatment but did not have to take any social precautions and had no lifestyle impact; moderate hyperhidrosis were patients who had to take social precautions, such as providing an extra shirt in axillary hyperhidrosis or having to constantly hold a small hand towel in palmar hyperhidrosis, but with no lifestyle impact; and severe hyperhidrosis were patients who not only took social precautions but had a major impact on lifestyle, such as avoiding social functions, change of job and emotional strain. Locations were categorised as palmar, axillary and facial hyperhidrosis (Table 1). Facial blushing being subjective is harder to define and was based more on the patient's perspective to the severity of the complaint as that with changes to their quality of life.
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Table 1 Grading of primary hyperhidrosis (mild hyperhidrosis – 1 point, moderate hyperhidrosis – 2 points, and severe hyperhidrosis – 3 points)
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2.2. Indications
The indications are given in Table 2. One hundred and thirty-eight patients had hyperhidrosis as the primary complaint. The most frequent indication was palmar hyperhidrosis (41%). Facial hyperhidrosis±facial blushing was present in only 17 patients and isolated facial blushing in eight patients.
2.3. Operative technique
General anaesthesia using single lung isolation technique with double lumen endotracheal tube was used in all patients. The patients were positioned in a semi-sitting position with their arms in abduction. Two sub-centimetre incisions were placed at the anterior axillary line in the 3rd and 4th intercostal spaces to allow passage of a 5 mm bladeless trocar (Ethicon Endo-Surgery Inc.) and a 2–3 mm bladeless trocar (Ethicon Endo-Surgery Inc.). One litre of carbon dioxide was insufflated under careful monitoring with a single injection period at the beginning of the procedure ensuring that the intrathoracic pressure did not rise above 10 mm Hg. The aim of this was to reduce the vacuum created, which would entrain room air that would be less soluble than carbon dioxide if not fully evacuated at the end of the procedure. A 5-mm diameter 30° thoracoscope (Dyonics, Smith+Nephew Inc.) was introduced followed by a 3 mm diathermy hook (Ethicon Endo-Surgery Inc.). All patients underwent division of their sympathetic chain using controlled intermittent electrocautery after identifying the first rib. The sympathetic chain was divided with a tailored approach according to the patient's predominant symptoms at the levels of T2 and T3 for palmar hyperhidrosis; a high T2 division for facial hyperhidrosis± facial blushing; T3,T4±T5 for axillary hyperhidrosis; and T2–T4±T5 for combined palmar and axillary hyperhidrosis. All procedures were successfully performed bilaterally in a single anaesthetic episode. Intra-pleural air was evacuated through a fluid filled syringe while the anaesthesiologist produced a Valsalva equivalent manoeuvre on the patient. A postoperative chest X-ray was performed in recovery to verify the absence of a significant pneumothorax. Patients were discharged the following day.
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3. Results
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All one hundred and sixty-three patients underwent bilateral thoracoscopic sympathectomy with a mean follow-up of 51 months (5–140 months). Patient demographics included 50 males (31%) and 113 females (69%) with a mean age of 29 years (range 10–66 years). Positive family history was noted in only 22% of patients. The median operating time was 35 min and one patient had an aberrant vessel arising from the subclavian artery to the upper lobe which was clipped and ligated. There was no mortality.
Results and recurrence rates are shown in Table 3 and Fig. 1. Palmar and/or axillary hyperhidrosis had success rates in the region of 96.4–98.5%. However, facial hyperhidrosis±blushing had lower success rates of 84%. Recurrence rates were in the region of 4.6–9.3% at a mean of 22 months (3–72 months).
Complications included pneumothorax requiring chest drain (4%), chronic wound pain six months (0.6%) and compensatory sweating (77%). There was one conversion to a minithorocotomy for bleeding at the end of the procedure. No cases of Horner's syndrome were identified. Compensatory sweating grading is as shown in Table 4. Based on this, 22.1% had no compensatory sweating, 52.8% had mild compensatory sweating, 22.7% had moderate compensatory sweating and 2.4% had severe compensatory sweating. Compensatory sweating occurred most frequently on the trunk (57.1%), followed by lower limbs (19.2%), abdomen/groins (18.4%), face (12.9%), and gustatory sweating (7.4%).
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Table 4 Grading of compensatory sweating based on severity (mild hyperhidrosis – 1 point, moderate hyperhidrosis – 2 points, and severe hyperhidrosis – 3 points) and location (face, trunk, abdomengroins, lower limbs and gustatory)
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Compensatory sweating increased with the number of sympathetic ganglia (>2 levels), which were divided by electrocautery (86% vs. 73.5%). When compensatory sweating was compared to the grading of the primary hyperhidrosis, there was a direct relationship, with grade A patients having 76.6% compensatory sweating, grade B patients having 80.9% compensatory sweating and grade C patients having 100% compensatory sweating.
The quality of life improved in approximately 85% of patients, remained unchanged in 10% of patients and worsened in 5% of patients. The reason for a worse quality of life was related to the severity of compensatory sweating, with mild compensatory sweating having 2.3%, moderate compensatory sweating having 13.5% and severe compensatory sweating having 50% poorer quality of life (Fig. 2). Eighty-nine percent of patients would undergo the procedure again when asked but the remaining 11% would not undergo the procedure for the following reasons; compensatory sweating (47.4%), failure of the operation/recurrence (42.1%), pneumothorax requiring chest drain (5.25%) and chronic wound pain >6 months (5.25%).
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Fig. 2. Number of patients whose quality of life worsened in relation to the severity of their compensatory sweating.
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4. Discussion
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The therapeutic options for the management of hyperhidrosis have traditionally been non-operative. These include topical antiperspirants, anti-cholinergic drugs, iontophoresis and more recently botulinum toxin injections. These methods seldom give sufficient relief, their effects are transient, compliance rates are low and they are not without associated side effects. Thoracoscopic sympathectomy is, however, a safe and effective method of managing these patients with significant improvement in quality of life [3]. A variety of different surgical approaches have been used with time with varying results [4]. The term ‘sympathectomy’ is often used synonymously with ‘sympaticotomy’, the former historically referring to the extirpation or destruction of the sympathetic ganglia and chain, and the latter referring to the division of the sympathetic chain. In our institution, we performed sympaticotomy, as it allowed fewer incisions, less external and internal tissue trauma, while producing equivalent clinical results, but like most previous reports, we refer to the procedure as sympathectomy.
The results of thoracoscopic sympathectomy over the last decade have continued to improve with a combination of better understanding of pathophysiology and also the recent advances in video-assisted endoscopic sympathectomy. However, there have been few long-term series. In our institution, the results for primary hyperhidrosis of the palmar and or axillary region have been comparable with other reports, >95% success [3]. Though the results for facial hyperhidrosis±blushing is in the mid-80%, this is also comparable with that published in reports [5]. The lower success rates for facial hyperhidrosis±blushing could be attributed to the greater awareness of the complication associated when performing high T2 sympathectomy, i.e. Horners's syndrome, and this has to be carefully considered when treating this group of patients.
This study demonstrates that thoracoscopic sympathectomy does provide long-term benefit with recurrence rates in the region of <10%. However, it is not without its complications, the most important being compensatory sweating, in the region of 67–85% [6, 7]. Is it therefore reasonable to remove one disorder to create another? Hederman [8] stated that patients who have sweating severe enough to cause significant occupational or social difficulties, and who have been cured by sympathectomy, are among the most grateful that surgeons will encounter in the course of their work. This can be seen in previous published reports on the significant improvement in the quality of life of these patients [9].
The variability of reported incidence of compensatory sweating could reflect the heterogeneity of the population, different surgical procedures being performed, or perhaps a consequence of different definitions of compensatory sweating [10]. Factors such as geographic location, working environment, humidity and temperature together with heterogeneity of the population can also affect the incidence of compensatory sweating. It has been speculated that compensatory sweating may be a thermoregulatory mechanism to compensate for the loss of secretory tissue, and for that reason it is related to both the surgical procedure and to the extent of resection/division of the sympathetic chain. Resection as opposed to division of the sympathetic chain has been shown to correlate with the severity of compensatory sweating because of the extensive areas of skin anhydrosis, which may be a prerequisite to this complication but with similar results between the two procedures [3, 11]. When considering the extent of sympathectomy, there are many views; some authors believe that limiting the extent of sympathectomy may reduce the compensatory sweating [8, 12]; others believe that even a limited sympathectomy resulted in compensatory sweating in all patients [13, 14]; and finally some others believe that the extent of sympathectomy does not influence the occurrence of compensatory sweating [13, 15].
Most published reports do not define the severity of the primary hyperhidrosis nor the severity of compensatory hyperhidrosis, and often refer to them subjectively. Some authors consider compensatory sweating to occur when there is a slight increase in perspiration, while others consider it when there is massive perspiration [4]. We have attempted to define the above as we believe that if compensatory sweating is purely a thermoregulatory response in view of loss secretory tissue, then the amount of sweat loss in the primary complaint should be responsible for the amount of thermoregulation needed to compensate for this. We found that in proportion to the severity of the primary complaint there was a proportional number of patients affected by a compensatory sweating. This is especially important as all the patients whose quality of life worsened related this to compensatory sweating, with the severity of the compensatory sweating increasing in line with quality of life diminution. We acknowledge that the correlation between the grade of primary hyperhidrosis with compensatory sweating and the grade of compensatory hyperhidrosis with quality of life will require more detailed future prospective studies to confirm these findings.
In conclusion, bilateral thoracoscopic division of the sympathetic chain as opposed to resection is safe and effective when performed by trained thoracic surgeons and anesthesiologists, with excellent results for appropriate indications. There is clearly an improvement in the quality of life in the majority of patients, with a significant number willing to undergo the operation again if need be. However, these patients need to be fully informed of the complications, especially compensatory sweating, which can be severe in a significant minority of cases.
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References
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Abstract
1. Introduction
