One-Year Follow-Up After Thoracoscopic Sympathectomy for Hyperhidrosis: Outcomes and Consequences

Transcription

1 One-Year Follow-Up After Thoracoscopic Sympathectomy for Hyperhidrosis: Outcomes and Consequences Todd M. Dewey, MD, Morley A. Herbert, PhD, Sherry L. Hill, Syma L. Prince, RN, and Michael J. Mack, MD Medical City Dallas Hospital, and Cardiopulmonary Research Science and Technology Institute, Dallas, Texas Background. Thoracic sympathectomy is recognized as an effective treatment for patients with severe hyperhidrosis. While good early results have been documented, continuing efficacy and patient satisfaction has not been well-defined. We reviewed our results in patients who were at least one year out from surgery. Methods. All procedures were performed thoracoscopically using bilateral 3 mm ports and excision of a segment of the sympathetic chain by electrocautery. The level of sympathectomy depended upon clinical symptoms: T 2 for face/scalp, T 3 for palmar hyperhidrosis, and T 4 for axillary hyperhidrosis, or a combination of levels for multiarea sweating. All patients were followed-up at least 1 year postprocedure by mail questionnaire and/or telephone. Results. Two hundred twenty-two patients had undergone thoracoscopic sympathectomy for essential hyperhidrosis between Jan 1, 2002 and Nov 30, 2003, with 170 patients having at least one-year follow-up. The patients preoperative assessment of the severity of sweating in the affected areas was compared with their one-year evaluation in order to determine the durability of the procedure. All affected areas continued to show significant improvement in sweating as compared with preoperative symptoms. Compensatory sweating was reported in 85% of our patients at one-year follow-up. Patients with a T 2 lesion were significantly more likely to have severe compensatory sweating than those with other levels; 48.8% vs 16.1% (p < 0.001). Patients with levels other than T 2 reported high degrees of satisfaction unrelated to their postoperative compensatory symptoms. Conclusions. Patient satisfaction and perceived effectiveness with sympathectomy for palmar or axillary hyperhidrosis remain high even one year after the procedure. Inclusion of the T 2 lesion results in significantly more severe compensatory sweating and reduced satisfaction than other levels. (Ann Thorac Surg 2006;81: ) 2006 by The Society of Thoracic Surgeons Hyperhidrosis is an idiopathic condition characterized by localized sweating in excess of the bodies physiologic requirements. With a reported incidence of approximately 1% of the population, this condition may affect up to 2.5 million people in the United States alone [1]. The most common areas affected include the palms, feet, axilla, scalp, or face. Severe noncontiguous blushing of the head and neck has also been described in association with the abnormal perspiration. Secondary hyperhidrosis, usually manifested by increased total body sweating, can be associated with systemic diseases such as hyperthyroidism, lymphoma, pheochromocytomas, or central nervous system abnormalities. This condition can be socially, psychologically, and professionally stigmatizing in the most affected patients. The manifestation of excessive localized sweating generally occurs either spontaneously, or in association with Accepted for publication Nov 3, Presented at the Forty-first Meeting of The Society of Thoracic Surgeons, Tampa, FL, Jan 24 26, Address correspondence to Dr Herbert, Medical City Dallas Hospital, 7777 Forest Lane, Ste C-740, Dallas, TX 75230; morley.herbert@ hcahealthcare.com. stressful or emotionally charged situations. Patient symptoms generally begin in childhood or early adolescence, around the time of puberty, and rarely improve with age. Severely affected patients have been known to refuse professional advancement if the resulting promotion would increase the likelihood of exposing their condition. Surgical treatment for hyperhidrosis has been described as early as the 1920s, primarily utilizing a thoracotomy approach [2]. This aggressive approach was associated with significant patient morbidity and a protracted recovery period and failed to generate widespread support. Medical management of hyperhidrosis has been poorly effective, often leading many patients to try multiple unsuccessful treatment modalities. Advances in video-assisted thoracoscopic surgery, utilizing microinstrumentation, have allowed surgical sympathectomy to become a viable first-line therapy for hyperhidrosis. We have previously reported good early results with thoracoscopic sympathectomy utilizing a surgical technique of excision of the sympathetic ganglia at the level of the second rib for facial/scalp sweating, the third rib for palmar sweating, and the fourth rib for axillary 2006 by The Society of Thoracic Surgeons /06/$32.00 Published by Elsevier Inc doi: /j.athoracsur

2 1228 DEWEY ET AL Ann Thorac Surg HYPERHIDROSIS SYMPATHECTOMY ONE-YEAR FOLLOW-UP 2006;81: Table 1. Demographics for Patients in Study with One Year Follow-Up (170 patients) Demographics No. % Gender Female 102/ Race Black 6/ Caucasian 133/ Hispanic 12/ Asian 19/ Length of Problem Lifelong problem 89/126 a 70.6 Not lifelong problem 37/126 a 29.4 If not Lifelong, Mean No. Years Suffered from problem Mean patient age (years) Positive family history (with 69/153 a 45.1 primary relative) Received previous treatment 90/128 a 70.3 Drysol 72/128 a 56.3 Other 28/128 a 21.9 Drionics 19/128 a 14.8 Topical agent 9/128 a 7.0 Botox 7/128 a 5.5 Beta blockers 3/128 a 2.3 Anticholinergics 2/128 a 1.6 When are episodes of extreme sweating triggered? Daily activities 106/ Nervous, emotional situations 106/ Unexpectedly 105/ Exercise 85/ Using hands 84/ Sleep 22/ a Indicates that fewer than 170 patients responded to the question. sweating [3]. Multiple areas of excision were employed for multilevel sweating. The early results were promising, but continuing efficacy and patient satisfaction were unknown. To evaluate the durability of this surgical approach for hyperhidrosis, we retrospectively reviewed the results of patients at least one year out from time of surgery. (3.5%). The majority of patients (70.6%) described their hyperhidrosis as being lifelong, with the remainder (29.4%) having been affected on average for years. Hyperhidrosis affecting a primary relative was reported by 69 patients (out of 153 reporting; 45.1%). Ninety patients (out of 128 reporting; 70.3%) had tried some form of treatment (topical agents, oral medications, iontophoresis, or Botox injections) before undergoing surgery (Table 1). The most frequent presenting complaint was palmar sweating in 60 patients (35.3%), followed by palms and axilla, axilla alone, and scalp and palms. A large number of patients (18.2%) reported all of the above areas (Table 2.) The most frequently identified triggers for initiating sweating were emotional or stressful situations, and undergoing normal daily activities. All patients participated in an in-depth group seminar prior to surgery in which the incidence of hyperhidrosis, alternative forms of treatment, and the results and complications of thoracoscopic sympathectomy were discussed in detail. Additionally, patients were required to fill out a detailed questionnaire preoperatively, postoperatively, and at 1 year from the time of their surgical procedure. The questionnaires were used in order to quantify the degree and location of their hyperhidrosis using a 1 to 10 ranking scale. Early and late surgical results and one-year complications were also collected by means of a collection tool, which again utilized a subjective 1 to 10 scale for the questioned fields. The numbers of patients shown in the tables and graphs includes only those responding to that question. Operative Technique All procedures are performed under general anesthesia using a double lumen endotracheal tube for isolated lung ventilation and with the patients supine with their arms extended. A radial arterial line is always placed for continuous blood pressure monitoring. Three 3 mm incisions are performed in the right inframammary crease with the most medial directly below the areola and the most lateral near the tail of the breast. Three sealed thoracoscopic ports are then placed, and carbon dioxide (CO 2 ) insufflated to aide in exposure of the sympathetic chain. Maximum insufflation pressure is set for less than 8 mm Hg in order to avoid mediastinal shift and hypotension. A 30 degree, 3 mm endoscope is inserted into the Patients and Methods Between January 1, 2002 and November 30, 2003, 222 patients had undergone thoracoscopic sympathectomy for essential hyperhidrosis. After receiving Institutional Review Board approval, operative and follow-up data were obtained on the patients. One year follow-up data were available on 170 patients (76.6%). There were 68 males (40%) and 102 females (60%), with an average age of years old. The youngest patient was 13 years old and the oldest 76 years of age. Caucasians comprised 78.2% of the study group, with smaller proportions of Asians (11.2%), Hispanics (7.1%), and blacks Table 2. Distribution of Patient Sweating Complaints at Presentation Body Area Patients (%) With Compensatory Sweating Palms 60 (35.3%) 49/60 (81.7%) Palms & axilla 48 (28.2%) 40/47 (85.1%) a Axilla 12 (7.1%) 8/12 (66.7%) Scalp & palms 7 (4.1%) 7/7 (100%) Face/Scalp 5 (2.9%) 3/5 (60.0%) Scalp & axilla 7 (4.1%) 6/6 (100%) a All of the Above 31 (18.2%) 30/31 (96.8%) a One patient failed to answer the question in these groups.

3 Ann Thorac Surg DEWEY ET AL 2006;81: HYPERHIDROSIS SYMPATHECTOMY ONE-YEAR FOLLOW-UP center port, and a small curved grasping instrument and a monopolar hook cautery inserted into the other ports. The chest wall is then meticulously inspected and the first rib identified. The lower level ribs are then identified based on the position of the first rib and a cautery score placed on the body of the third rib to mark it s location. This is done to ensure that we can always correctly identify the appropriate level of transection, as it is easy to become disoriented with the small visual field associated with a3mmendoscope. The sympathetic chain is then identified and the parietal pleura opened over the nerve at the selected ganglion level. We excise a very small segment of the T 2 ganglia for patients with face/ scalp hyperhidrosis, T 3 for palmar symptoms, and the T 4 ganglion for patients with axillary hyperhidrosis. When treating patients for more than one area, multiple segments are excised, while the rest of the chain is left intact. If accessory fibers and the Kuntz nerve are found, they are ablated with the cautery. Local anesthetic using 0.25% Marcaine with epinephrine is then instilled into the sympathectomy bed to decrease postoperative pain. The CO 2 is then evacuated from the chest with a small catheter under water seal as the lung is gently reinflated. The port sites are closed with skin glue and the contralateral side performed in a similar fashion. Patients are then observed in the post anesthesia care unit, and ultimately discharged home generally within 2 to 3 hours after the procedure. Routine chest x-rays in the recovery area are not performed. Data Collection All initial patient questionnaires collected at the group seminar are entered into a customized database at the time of the procedure. Patients are routinely followed with an office visit at three weeks after surgery and then on a yearly basis either by telephone or through the mail. The long-term data collected include postoperative complications including the severity of compensatory symptoms, late satisfaction with the procedure, and incidence of symptom recurrence. Data were stored in a database and exported to SAS (v9.1.3, SAS Institute, Cary, NC) for analysis. The 2 statistics, means, standard deviations, and t-tests were used as appropriate. Results There was no operative mortality or major intraoperative complication. No patients required conversion to an open procedure for either structural or vascular injury during the procedure. All patients were done as outpatients, and discharged the day of surgery. No patients required hospital admission and there were no cases of bleeding and none required conversion to an open procedure. One patient was identified with a pneumothorax at the completion of the procedure, having a persistent air leak on removal of air. They were treated with a Heimlich valve on a small catheter, had a chest x-ray and then were discharged home. Unilateral Horner syndrome was identified in one patient on follow-up and resolved completely within 6 weeks. One patient suffered 1229 Fig 1. Patient satisfaction with results of surgery. (black very satisfied; white satisfied; cross hatched very dissatisfied.) a unilateral rupture of a silicone breast implant requiring replacement of bilateral implants at a later date. Only one patient in this series was unable to return to work, school, or normal activities by postoperative day 3. This patient was a law enforcement officer who had to take a yearly physical endurance test and required an additional week to return to full strength. One year postoperative questionnaires were returned by 170 (76.6%) of the 222 treated patients. The mean time from operation to follow-up was years. Patients were asked to evaluate their one-year satisfaction with the procedure on a scale of 0 to 10 with 10 being the highest degree of satisfaction. This was then converted to a satisfaction rating based on patient response with scores of 0 2 classified as very dissatisfied, 3 7 as satisfied, and 8 10 as very satisfied. The most satisfied patients were those that had sympathectomy for palms only, palms and axilla, and axilla alone (see Fig 1). Patients with the highest degrees of dissatisfaction were those that had a T 2 level excision as isolated treatment of face/scalp hyperhidrosis, or T 2 in conjunction with any other level being performed [Fig 1]. Additionally, the patients preoperative assessment of the severity of sweating in their affected areas was compared with their one-year evaluation in order to determine the durability of the procedure (Table 3). All affected areas continued to show significant improvement in sweating as compared with preoperative symptoms. Although we did not surgically treat sweating of the feet, an estimated 50% to 75% of the patients who had surgery directed to palmar sweating alone, or in conjunction with other areas, noted significant improvement in sweating of their feet as evidenced by their scores. Compensatory sweating was reported in 85% of our patients on one-year follow-up. Patients were asked to evaluate the degree of compensatory sweating on a scale of 0 to 10 with 10 being the most severe symptoms. Table 2 also shows the fraction of patients reporting compensatory sweating based on their initial indications for surgery. The scores were then converted to a rating based on patient response with scores of 0 classified as no compensatory symptoms, 1 4 classified as mild symptoms,

4 1230 DEWEY ET AL Ann Thorac Surg HYPERHIDROSIS SYMPATHECTOMY ONE-YEAR FOLLOW-UP 2006;81: Table 3. Efficacy of Procedure at One Year Presenting Symptom Preoperative Severity Score Severity Score at 1 (0 10 Scale) a Year (0 10 Scale) Change in Score (p Value) Palms ( 0.001) Axilla ( 0.001) Face/scalp ( 0.001) Feet ( 0.001) a Severity scale goes from 0 (none) to 10 (maximum). 5 7 as moderate, and 8 10 as severe compensatory symptoms. Patients having sympathectomy for face/scalp alone and face/scalp, palms, and axilla reported the highest rates of severe compensatory sweating at 63% and 56%, respectively [Fig 2]. Conversely, patients having T 4 excisions for only axillary symptoms, or T 3 excisions for isolated palmar sweating, reported the lowest incidence of severe compensatory sweating at 0% and 11.1%, respectively [Fig 2]. The most frequent areas involved with compensatory sweating were the chest and back, legs, abdomen, thighs, and groin area. A univariate analysis was performed comparing operative excision levels including T 2 versus those procedures that did not have a T 2 excision for the frequency of mild, moderate, and severe compensatory hyperhidrosis. Patients having the T 2 ganglia excised as part of their procedure were significantly more likely to have severe compensatory symptoms as compared with patients not having T 2 removed; 48.8% vs 16.1% (p 0.001) [Fig 3]. Patients were also queried (yes/no/undecided) as to whether they would undergo the procedure again, now knowing their postoperative results and degree of compensatory symptoms. Patients having sympathectomy for either isolated hyperhidrosis of the palms or axilla or in combination overwhelmingly indicated that they would have the procedure again [Fig 4]. In contrast, a significant percentage of patients with T 2 excisions for either isolated face/scalp sweating or in combination with other areas reported they would not undergo the procedure again. The only exception was patients in which palmar symptoms were a predominate part of their symptomatology in addition to facial/scalp sweating. These patients indicated that they would undergo the procedure again. Overall, patients were significantly more likely to report that they would not undergo surgery again at one year than at their 3-week office visit; 11.8% vs 5.9% (p 0.001). Comment Endoscopic sympathectomy has proven to be an efficacious and durable surgical treatment for severe primary hyperhidrosis. Thoracic sympathectomy has also been recognized as having beneficial effects for the treatment of reflex sympathetic dystrophy, Raynaud s disease, and upper extremity ischemia in addition to hyperhidrosis [4]. The surgical approach is predicated upon interrupting the transmission of impulses from the sympathetic nerve ganglia to the involved eccrine sweat glands. This report demonstrates the effectiveness of T 2 resection for face/scalp hyperhidrosis, T 3 for palmar symptoms, and T 4 for axillary sweating. On follow-up, patients reported persistently reduced sweating of their previously affected areas. Still, there are numerous reports in the literature documenting acceptable results utilizing a plethora of energy sources and surgical approaches, which makes comparison of series difficult [5 9]. Licht and Pilegaard [10] describe a technique of sympathectomy, or nerve division, that includes the T 2 ganglia in all cases, irrespective of the area of excessive sweating, that has yielded good relief of symptoms. Likewise, Gossot and colleagues [11] report good results and patient satisfaction with excising the entire sympathetic chain from T 2 to Fig 2. Compensatory sweating as function of surgical levels. (grey none; cross-hatched mild; white moderate; black severe.) Fig 3. Change in compensatory sweating when T2 is included. (black including T-2 level; white no T-2 level.)

5 Ann Thorac Surg DEWEY ET AL 2006;81: HYPERHIDROSIS SYMPATHECTOMY ONE-YEAR FOLLOW-UP Fig 4. Response to Would you repeat surgery? as function of surgical level. (black no; grey undecided; white yes.) T 4. The theoretic possibility of procedural reversibility with clamping the nerve instead of resection or ablation in the event of severe compensatory symptoms has led some authors to advocate leaving the nerve in continuity. This approach only makes physiologic sense if the clip were removed relatively soon postoperatively in order to avoid neural cell death. In our experience, the desire for early reversal of the procedure after sympathectomy is rare. And as severe compensatory sweating would be the most likely inciting agent, refraining from interrupting the ganglia at the T 2 level would probably be more effective than a semireversible procedure. Our approach has been to completely interrupt transmission of sympathetic impulses by excising a small portion of the chain as it crosses the costal heads of the ribs. This technique has shown good early and one-year results for the treatment of excessive sweating with little operative morbidity. However, major operative complications from sympathectomy have been reported. Cameron [12] has reported one death and another major neurologic injury related to CO 2 insufflation. Additionally, other authors [13 15] have reported major vascular injuries and thoracic duct injuries leading to the development of chylous effusions. These reports emphasize the need for meticulous technique in landmark identification, which can be difficult using small endoscopes with limited fields of vision. Compensatory sweating continues to be the most common side effect of thoracic sympathectomy, and was reported in 85% of our patients. Nevertheless, the reported incidence of compensatory sweating after sympathectomy varies throughout the literature. Zacherl and colleagues [5] report an incidence of only 69% in a series of 352 patients. In contrast, Fredmann and colleagues [16] reported that 90% of their patients had compensatory sweating postoperatively. This variability likely reflects the heterogeneity of the patient populations, as well as the variability in surgical technique, patient follow-up, and classification of compensatory sweating. Accurately defining compensatory sweating into quantifiable categories remains a challenge due to the subjectivity of the symptom. It has also been noted that the frequency of patients reporting of compensatory symptoms is highest 1231 in the summer and lowest in the winter. Therefore, geographical differences between reporting centers likely also plays a role in reported frequency of compensatory sweating. Gustatory hyperhidrosis, while a recognized side effect after thoracic sympathectomy, was not a significant finding in this population. The trigger for eliciting gustatory hyperhidrosis is thought to be the consumption of spicy or acidic foods [10]. The etiology of this symptom is unclear, but Hashmonai and colleagues [17] speculate that it may be a result of the ingrowth of vagal nerve fibers into the severed sympathetic chain. It has been hypothesized that compensatory sweating is a thermoregulatory mechanism by which the sweat glands attempt to compensate for a decreased amount of secretory tissue [18]. Using Berkow s surface area formation, Shally and Florence [19] demonstrated that sweat gland function diminished as much as 40% after sympathectomy. Secondarily, many authors felt that compensatory symptoms could be reduced or eliminated by limiting the extent of sympathetic nerve excision. This study demonstrates that while the frequency of compensatory sweating may not be reduced, the severity of those symptoms can be correlated to both the level and extent of resection. Our results demonstrate that compensatory sweating is significantly more likely to be severe in those patients who had the T 2 ganglia excised. Additionally, there was also a strong correlation between the number of levels excised and the degree of compensatory sweating. The more sympathetic segments excised, especially those including T 2, the greater the incidence of severe compensatory symptoms. These results were consistent with the findings that the most satisfied patients at one-year follow-up were those who did not have a resection of the T 2 ganglion. The only exception would be those patients who had a T 3 resection for palmar symptoms in addition to the T 2 resection for facial/scalp sweating. This is probably due to the fact that palmar hyperhidrosis is the most socially and professionally inhibiting, and removal of this problem overshadows the discomforts associated with compensatory sweating. Based on these findings, we currently limit the extent of our resections for hyperhidrosis to a single level if possible in order to reduce the incidence of severe compensatory symptoms. In the event that patients have severe multisite sweating, or if sweating involves the face/scalp and would require a T 2 resection, we would recommend detailed counseling of the patient in regards to the increased likelihood of experiencing severe compensatory sweating. Hederman [20] stated that the most grateful patients that surgeons will ever encounter are those who have been cured of professionally or socially inhibiting sweating by sympathectomy. However, long-term patient satisfaction with the procedure is ultimately dependent upon a perception of few or manageable postoperative side effects once the euphoria over improvement in their hyperhidrosis dissipates. This report demonstrates a clear correlation between the severity of compensatory symptoms and the level and extent of ganglionic resection. Therefore, it is important to continue to develop

6 1232 DEWEY ET AL Ann Thorac Surg HYPERHIDROSIS SYMPATHECTOMY ONE-YEAR FOLLOW-UP 2006;81: technical refinements in the procedure in order to minimize postoperative complications. References 1. Drott C, Claes G. Hyperhidrosis treated by thoracoscopic sympathectomy. Cardiovasc Surg 1996;4: White JC, Smithwick RH, Allen AW, et al. A new muscle splitting incision for the resection of the upper thoracic sympathetic ganglia. Surg Gynecol Obstet 1933;56: Doolabh N, Horswell S, Williams M, et al. Thoracoscopic sympathectomy for hyperhidrosis: indications and results. Ann Thorac Surg 2004;77: Claes G, Drott C, Gothberg G. Thoracoscopy for autonomic disorders. Ann Thorac Surg 1993;56: Zacherl J, Imhof M, Huber ER, et al. Video assistance reduces complication rate of thoracoscopic sympathectomy for hyperhidrosis. Ann Thorac Surg 1999;68: Lin T-S, Fang H-Y. Transthoracic endoscopic sympathectomy in the treatment of palmar hyperhidrosis with emphasis on perioperative management. Surg Neurol 1999;52: Goh PM, Cheah WK, DeCosta M, et al. Needlescopic thoracic sympathectomy: treatment for palmar hyperhidrosis. Ann Thorac Surg 2000;70: Fox AD, Hands L, Collin J. The results of thoracoscopic sympathetic trunk transection for palmar hyperhidrosis and sympathetic ganglionectomy for axillary hyperhidrosis. Eur J Vasc Endovasc Surg 1999;17: Reisfeld R, Nguyen R, Pnini A. Endoscopic thoracic sympathectomy for hyperhidrosis: experience with both cauterization and clamping methods. Surg Laparosc Endosc Percutan Tech 2002;12: Licht PB, Pilegaard HK. Severity of compensatory sweating after thoracoscopic sympathectomy. Ann Thorac Surg 2004; 78: Gossot D, Galetta D, Pascal A, et al. Long-term results of endoscopic thoracic sympathectomy for upper limb hyperhidrosis. Ann Thorac Surg 2003;75: Cameron AEP. Complications of endoscopic sympathectomy. Eur J Surg Suppl 1998;580: Cheng W, Chang C, Lin T. Chylothorax after endoscopic sympathectomy: case report. Neurosurgery 1994;35: Gossot D. Chylothorax after thoracic endoscopic sympathectomy. Surg Endosc 1996;10: Gossot D, Kabiri H, Caliandro R, et al. Early complications of thoracic endoscopic sympathectomy: a prospective study of 940 procedures. Ann Thorac Surg 2001;71: Fredmann B, Zohar E, Shachor D, et al. Video-assisted transthoracic sympathectomy in the treatment of primary hyperhidrosis: friend or foe? Surg Laparosc Endosc Percutan Tech 2000;4: Hashmonai M, Kopelman D, Kein O, et al. Upper thoracic sympathectomy for primary palmar hyperhidrosis: longterm follow-up. Br J Surg 1992;79: Sung SW, Kim JH. Ultra-thin needle thoracoscopic surgery for hyperhidrosis with excellent cosmetic effects. Eur J Cardiothorac Surg 2000;17: Shally WB, Florence R. Compensatory hyperhidrosis after sympathectomy. N Engl J Med 1960;263: Hederman WP. Endoscopic sympathectomy. Br J Surg 1993; 80: DISCUSSION DR JOSE RIBAS MILANEZ DECAMPOS (São Paulo, Brazil): Excellent paper, excellent results, and they are very important because more and more patients are looking for this type of surgery, and we are operating on some very young people. My first question is: Did you include a quality of life questionnaire in your follow-up? My second question is regarding your results: Would you ever recommend the resection of T 2? I think that this is the most important message in your paper, and then, you show us the good results in operating T 3. In conclusion, we recommend as you do, the limited sympathectomy of T 3, and we avoid, as much as possible, operating the T 2 sympathetic ganglia. DR DEWEY: Thank you. We would recommend trying to avoid T 2 level resections if at all possible. I think there are a lot of people and there are a lot of results published in the literature where people routinely resect T 2 and still get good results. I think, though, if you talk to patients one year after resection when the euphoria of the reduction of their sweating is gone, the thing they most focus on is their compensatory symptoms. So because this is an elective procedure and long-term patient satisfaction is probably going to be predicated upon how bad their compensatory symptoms are, we have elected in our practice to try and not routinely resect T 2, or if we do, we spend much more time detailing and counseling the patients that they can expect a fairly significant risk of compensatory symptoms. DR MARK J. KRASNA (Baltimore, MD): Todd, that was an excellent presentation. As you know, Mike and I started about, I guess, 11 years ago doing this the same way, which is the three-incision approach and excision. In 93 when I returned from some time I spent with Dr Claes in Sweden, I was converted to his single-incision technique. And probably in addition to the fact that my single 7 mm incision is smaller than your three 3 mm incisions, more importantly, I think that it is not necessary to resect or excise as opposed to just cut the nerve. So one of the questions I d like to ask is, is it possible that your high incidence of compensatory sweating with T 2, which is actually counter to what some people around the world have found, may be related to the difference in your technique? Our recent series from my colleagues and I in Maryland, on over 396 cases, had only a 2% severe compensatory sweating rate, although about 40% had some. We no longer resect it. We do cut T 2 as well as the nerve of Kuntz, but we didn t see that high a degree of severe compensatory sweating. My second question obviously gets to the statistics. I actually enjoyed the graphs because it does help sort things out. The total number of patients didn t have complete follow-up. When you go back to your original group, and I think you guys have over 280 by now, is this in fact something that you re seeing across the board? Is it something that s dependent on the level that you cut or is it possible that this is simply dependent on the disease with which the patients present? Is it that someone who shows up with a disease that requires T 2 to be cut perhaps is more predisposed to compensatory sweating, whether it s because of differences in counseling; psychological or otherwise? I enjoyed the paper. DR DEWEY: I think those are all good questions. I think if you ask 5 guys who do sympathectomy for hyperhidrosis, you re going to get 5 opinions on the levels that should be done and how it should be done. If you read the literature, you ll find people who cut the nerve, people who resect the nerve, and people who put clips on the nerve, feeling that potentially you

7 Ann Thorac Surg DEWEY ET AL 2006;81: HYPERHIDROSIS SYMPATHECTOMY ONE-YEAR FOLLOW-UP could reverse the operation if the patients return with severe compensatory symptoms. I think that these patient populations are a mixed bag and I think that it s hard to quantify objectively a subjective symptom. We have found in our experience that our complaints of compensatory symptoms are worse in the summer and not quite so bad in the winter, and we also found that our complaints of compensatory symptoms really have to do with personality type as well. This attempt was really to try and reinforce what our subjective opinion is, not only preoperatively seeing the patients but our postoperative complaints. The people who have severe compensatory symptoms, you ll know about it because they will be calling you every week for the rest of their life. So because this is an elective procedure, our focus really is to minimize the complications of the elective procedure while trying to do the most benefit. And I think only time will tell as to whether cutting or clipping or excising is the best, and the only way to know is to accrue a large enough patient population where we can objectively look at it. DR M. BLAIR MARSHALL (Washington, DC): I have a few questions. One, I m surprised that you operate on patients without having them have some form of treatment beforehand. Could you comment on that? I think in one of the Asian countries, recently, they made it illegal to do a sympathectomy on patients less than 20 because of potential adverse effects. Many of these patients are very young and one could actually ruin their lives. Do you insist that these patients fail some type of initial therapy? 1233 My second question is: There s some data to suggest that this procedure decreases the heart rate of patients by 10%. Did you look for this and do you offer this procedure to athletes? Lastly, do you think that the degree of compensatory sweating is proportional to the amount of preoperative sweating and have been able to examine this? DR DEWEY: Thank you. I think if there was a good nonsurgical treatment, we would be willing to try that. In our experience, the topical agents, the oral anticholinergics, the beta-blockers have not been effective, and, in fact, the side effects of those treatments are often worse than the hyperhidrosis itself. I think Botox is effective. A lot of people s insurance plans won t pay for it, and it s about $500 per treatment. So it s tough to get people to pay $500 out of their pocket when their insurance company will actually support a treatment which we feel is very efficacious. We do look at heart rate control in patients, and a couple years ago we did a study where we measured, basically, exercise performance in people preoperatively and postoperatively, and I think we subjectively saw that there was a small decrease in heart rate, but we couldn t quantify it. I think our approach would be, if we have an athlete or, say, an Olympic-caliber athlete in which aerobic capacity is a major function of their ability to compete, especially in sports where the degree of separation between first and second is in microseconds, we would probably counsel those patients to wait until after they are done competing prior to having a sympathectomy.