Bilateral Simultaneous T3/T4 Endoscopic Thoracic Sympathectomy for Treatment of Primary Palmar and Axillary Hyperhidrosis

Bilateral Simultaneous T3/T4 Endoscopic Thoracic Sympathectomy for Treatment of Primary Palmar and Axillary Hyperhidrosis

Mohamed Lasheen, MD.

Department of General Surgery, Ain Shams University, Cairo, Egypt.

Objective: This study was conducted to evaluate the safety, and complications of bilateral simultaneous endoscopic thoracic sympathectomy by resection of T3/T4 sympathetic ganglia in treatment of primary palmar and axillary hyperhidrosis.

Patients and methods: This prospective study was conducted in General Surgery Unit at Ain Shams University Hospitals in the period from May 2012 to June 2014 on twenty patients. All cases underwent thoracoscopic sympathectomy of T 3, 4 ganglia on the right &left sides at the same setting. In this prospective interventional study, we had 20 patients with severe primary hyperhidrosis with failed medical treatment who underwent bilateral simultaneous Endoscopic Thoracic Sympathectomy (ETS).

Results: Of 20 patients there were 13 males (65%) and 7 females (35%). The mean age was 23.9 ±7.8. The mean operating time was 76.2 min. ± 21.4 min. all cases were completed laparoscopically and there were no serious intraoperative complications.

The average length of hospital stay was 2.8 days (range: 2-5 days). The average postoperative follow-up period was 14.6 months (range: 6-20 months).

Residual pneumothorax occurred in 3 patients (15%), Surgical emphysema on either side was seen in the early postoperative period in 3 patients (15%).

The postoperative intercostal pain was observed in all cases (100%). most patients (19/20:

95% of patients) experienced compensatory sweating of varying degrees in other parts of the body, which was bilateral and symmetrical, most commonly at the lower back.

Excessive hand dryness was reported in 8 patients (40%), one of them had to use moisturizing hand cream daily.Patients’ Satisfaction with the overall results of the operation were assessed

.Only one patient (5%) stated that they were ‘dissatisfied’ and regretted having undergone the

operation

Conclusion: ETS with T3/T4 ganglia resection is a safe method for patients complaining of severe palmar or combined palmar and axillary hyperhidrosis . From the results of this study, we recommend using smaller ports and performing a more limited approach (T3 or T4) to patients with moderate primary hyperhidrosis symptoms to avoid dissatisfaction due to severe compensatory sweating and palmar overdryness.

Key words: Palmar hydrosis, sympathectomy, surgery, thoracoscopy.

Introduction:

Hyperhidrosis is a condition of sweating greater than necessary for the maintenance of normal body thermoregulation. It may develop secondary to a variety of medical disorders or it may be primary.1

For severe primary hyperhidrosis, medical management is often frustrating leading many

patients to try multiple unsuccessful treatment modalities,2 Over the past couple of decades endoscopic    transthoracic    sympathectomy (ETS) has gained popularity as a minimally invasive endoscopic approach in performing thoracic           sympathectomy.3                                  Compensatory sweating is the most common side effect, and was thought to be due to a thermoregulatory

mechanism but it is believed now to be a

reflex response.1

The aim of this study is to evaluate the safety and complications of bilateral simultaneous endoscopic thoracic sympathectomy by resection at levels T3/T4 sympathetic ganglia in treatment of primary palmar and axillary hyperhidrosis.

Patients and methods:

This  prospective  study  was  conducted in General Surgery Unit at Ain Shams University  Hospitals  between  May  2012 to June 2014. It was carried out on twenty patients , the characters of the patients are listed in Table (1).

Patients with secondary hyperhidrosis, recurrent  hyperhidrosis  after  surgery, previous major thoracic surgery and those who were unfit for general anaesthesia were excluded.

All patients were subjected to clinical assessment by history taking and examination to avoid patients with secondary hyperhidrosis. Preoperative investigations were done to all patients which include CBC, bleeding profile, liver enzymes, renal function tests and ECG. Chest X-ray and pulmonary function test were also done to exclude pulmonary pathology.

All cases underwent endoscopic thoracoscopic sympathectomy of T 3, 4 ganglia on the right &left sides at the same setting. A postoperative chest x-ray was done before discharge. Patients were followed-up for one year.

Surgical technique:

The procedure was done under general anaesthesia with double lumen endotracheal tube to allow single lung ventilation. All patients were positioned in thoracotomy position Figure (1).

Pneumothorax was achieved with Verres needle using CO2 insufflations under continuous pressure of 14mmHg.three ports are introduced; the first 10mm (for 30 degree Camera) in the fifth intercostal space mid- axillary  line  the  second  one  5mm  in  3rd or 4th spaces anterior axillary line and the third10mm in 6th space anterior axillary line.

Using monopolar diathermy coagulation on a hook, excision of third & forth ganglia are done Figure (2). The rami communicans at the curves of ribs 3, 4 were also severed.

Patient was then repositioned and the procedure is repeated on the contralateral side.

Patients  received  oral  analgesic  agents for adequate pain control. All patients were discharged after exclusion of pneumothorax or any other serious complication & removal of the intercostal tube. Patients came for follow-up in outpatient clinic after 10 days for removal of stitches. All patients were advised preoperatively that follow-up was necessary. after 10 days,1 month, 6 months and 1 year.

All the patients were assessed for: Operative time ,hospital stay , intraoperative complications postoperative complications and degree of satisfaction which were assessed by simplified questionnaires at 1 month, 6 months and 1 year follow-up OPC visits. Degree of satisfaction was divided into four grades: very satisfied, satisfied, partially (not very) satisfied and dissatisfied. This classification regarding the satisfaction with the procedure was obtained spontaneously during a clinical interview with the patients.

Results:

In  this  prospective  interventional  study, we had 20 patients with severe primary hyperhidrosis with failed medical treatment who underwent bilateral simultaneous Endoscopic Thoracic Sympathectomy (ETS).

Operative results

Bilateral thoracic sympathectomy operations (T3-T4) were successfully completed in all patients under video-assisted thoracoscopic guidance. The mean operating time was 76.2 min. ±21.4 min.

There was no conversion to open thoracotomy , no vascular injury and no severe pleural adhesions. There were no serious intraoperative complications, such as massive hemorrhage, arrhythmia or sudden cardiac arrest.

The average length of hospital stay was

2.8 days (range: 2-5 days). The intercostal

tubes on both sides were removed on the

Figure (1): Patient position.

Figure    (3):    Locations    of    compensatory sweating

Figure (2): Excision of third ganglion.

Figure (4): Degree of satisfaction.

Table (1): Characters of the patients.

Table (2):  Efficacy rate at different sites in the study.

second post operative day after chest X-ray

confirming the absence of pneumothorax.

The average postoperative follow-up period was 14.6 months (range: 6-20 months). There were two cases of dropouts during the study.

There was no mortality in this study, and no Horner syndrome was observed.

Residual pneumothorax occurred in 3 patients (15%) as seen in the postoperative

chest    radiography,    complete     resolution occurred in all of them without intervention.

Surgical emphysema on either side was seen in the early postoperative period in 3 patients (15%).

The postoperative intercostal pain was experienced  by  all  cases  (100%)  which was treated by opioids (Pethidine) for only

24  hours  after  surgery.  Later  on  it  was successfully managed with NSAIDs.

Mean basal heart rate before the procedure was 78.7 bpm ±8.5 while mean basal heart rate 10 days after was 74.5 bpm ±10.3. There was about 5.3% decrease in the postoperative mean

Efficacy rate at different sites are shown

in Table (2).

Most of the patients (19/20; 95%) experienced compensatory sweating of varying degrees in other parts of the body, which was bilateral and symmetrical, most commonly at the lower back. The locations of compensatory sweating are summarized in Figure (3).

Compensatory sweating was graded as: Grade 1: No CS, Grade 2: mild (minor), Grade 3: moderate (embarrassing) and Grade

4: severe (disabling or incapacitating). The percentage  of  compensatory  hyperhidrosis in the patients according to these grades was: Grade 1 in 1 patients (5%), Grade 2 in 12 patients (60%), Grade 3 in 6 patients (30%), and Grade 4 in only one patient (5%).

Excessive hand dryness was reported in

8 patients (40%), especially during winter. Only one patient (5%) stated that her hands became too dry to be accepted and had to use moisturizing hand cream daily.

Patients’ Satisfaction with the overall results of the operation was assessed by simplified questionnaires at 1 month, 6 months and 1 year follow-up OPC visits. Regarding the degree of satisfaction indicated by the patients at the end of the study, Only one patient(5%) stated that she were ‘dissatisfied’ and regretted having undergone the operation Figure (4).

Discussion:

This study involved a series of 20 patients of palmar with or without associated axillary hyperhidrosis who underwent video-assisted bilateral endoscopic thoracic sympathectomy (ETS). There is noticeable paucity of the series that investigate the resection of T3/T4 ganglia in literature. So, in this study we have chosen to study sympathectomy at level T3/ T4 and to evaluate the safety or (outcome) and the incidence of complications.

In  this  study  the  mean  operating  time

was  relatively  longer  (76.2  ±21.4  min.) compared to other studies as that done by Katara4 (35 min.) and Stefaniak5 that studied T3/T4  clipping  (57  min.).  This  is  mostly because  we  used  the  lateral  position  that requires repositioning of the patient during the procedure in addition to the 2 ganglia resection technique that consumes more time .

In this study the average length of hospital stay was 2.8 days (range: 2-5 days) which was slightly higher than that done by Stefaniak where it was 1.3 days. Whereas it was similar to the study done by Çubuk6  in which was

2.7 days.2-8

we had no cases of hemothorax in the 20 patients (0%). This was similar to studies by Kim,7 and Mahdy.8

Very few recent series encountered Horner′s syndrome as in study done by Yazbek9 where only 1 patient (out of 60) had transient Horner′s syndrome mostly due to heat transmission with adhesiolysis. In this study, the incidence of Horner′s syndrome was 0% which was similar to most of the studies in recent literature.

The most common complication is pneumothorax as mentioned by Liu10 who reported 3 patients (2.1%) with unilateral pneumothorax not requiring drainage. While Chen,11 reported 5 patients (11%) with unilateral pneumothorax and none of them required chest drainage ,we encountered 3 cases (15%) with pneumothorax in the early postoperative period,3 out of them were minimal and insignificant and only one case (5%) required chest drainage for 4 days.

Surgical emphysema is infrequently reported in literature although it is not uncommon.  Chang12   reported  that  32.5% of their patients developed subcutaneous emphysema, while in a study done by Moya13 surgical emphysema was found in about 1% of patients.

The rate of surgical emphysema in this study was 3 patients (15%). They were detected  both  clinically  and  radiologically

.All cases were managed conservatively and it resolved completely within 2 weeks.

Compensatory   sweating   (CS)   of   the trunk and lower limbs In a study by Mahdy

et al14 was 60% with T2, 45% with T3 and

10%  with  T4.  While  Yang15   showed  that the  overall  incidence  of  CS  was  44.7% after T4 sympathectomy and 70% with T3 sympathectomy.

In the present study where T3/T4 sympathectomy was performed, the total incidence of compensatory sweating of any degree was 95%. The mild form was detected in  60%;  the  moderate  form  was  detected in 30% and the severe disabling form was detected in only one case .

Excessive  palmar  dryness  was  reported

by Chang12 in 8.6% for T4 sympathectomy,

39.7% for T3, and 36% for T2. While Liu9 noticed dry hand in group T4 (1.4%) and, in group T3 (12.9%). In this study where T3/ T4 sympathectomy was performed, 40% of patients (8 cases) complained of excessive hand dryness that was tolerable to most except for one of them (5%). These results are not far from T3 sympathectomy results mentioned in other series and this slightly higher incidence may be due to the combined T3/T4 approach.

According   to   Chwajol   et   al.,   200916

satisfaction rates after endoscopic thoracoscopic sympathectomy reported was

90%.while Loscertales17 in 2004 in a study of

226 patients, found that 97% of their patients said they would undergo the operation again. in this study, Only one patient (5%) stated that she were ‘dissatisfied’ and regretted having undergone the operation.

Conclusion:

From this study we have concluded that endoscopic thoracoscopic sympathectomy with T3/T4 ganglia resection is effective and safe method for patients complaining of severe palmar or combined palmar and axillary hyperhidrosis with acceptable side effects leading to high degrees of patient satisfaction and improvement in the quality of life. From the results of this study, we recommend using ports 5 mm. to reduce postoperative chronic pain and incidence of surgical emphysema. owing to the high incidence of compensatory sweating and hand over dryness with T3/T4 resection, we recommend performing a more limited approach (T3 or T4) to patients with

moderate  primary  hyperhidrosis  symptoms to avoid dissatisfaction due to severe compensatory sweating and palmar over dryness.

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