Thoracoscopic Sympathicotomy for Disabling Palmar Hyperhidrosis: A Prospective Randomized Comparison Between Two Levels

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1 Thoracoscopic Sympathicotomy for Disabling Palmar Hyperhidrosis: A Prospective Randomized Comparison Between Two Levels Fritz J. Baumgartner, MD, Maria Reyes, Grant G. Sarkisyan, MD, Alicia Iglesias, PA, and Elizabeth Reyes Doctors Outpatient Surgery Center, Fountain Valley, California Background. Thoracoscopic sympathicotomy is highly effective in treating disabling palmar hyperhidrosis. The ideal level to maximize efficacy and minimize the side effect of compensatory hyperhidrosis (CH) is controversial. This study compared sympathicotomy over the second (R2) vs third (R3) costal head relative to these variables in patients with massive palmar hyperhidrosis. Methods. This prospective, randomized study enrolled 121 patients with disabling palmoplantar hyperhidrosis assigned to bilateral sympathicotomy (sympathetic transection), which was done over R2 in 61 (n 122 extremities) or R3 in 60 (n 120 extremities). Patients were questioned at 6 months and at 1 year or more to assess efficacy, side effects, and satisfaction with the procedure. Results. Sympathicotomy at R2 failed to cure palmar hyperhidrosis in 5 of 122 (4.1%) extremities, but only 2 (1.6%) were to a truly profound dripping level of recurrence. Sympathicotomy at R3 failed to cure palmar hyperhidrosis in 5 of 120 extremities (4.2%), and all were dramatic failures with dripping recurrent sweating. The patients whose palmar hyperhidrosis was not completely cured were aged vs years (p 0.04). Two R3 patients with failure underwent three redo R2 sympathicotomies, with curative results. R2 patients showed a trend toward a higher level of CH vs R3 patients at 6 months and after 1 year. The CH severity scale was (n 38) for R2 vs (n 36) for R3 (p NS) at 6 months and (n 43) for R2 vs (n 37) for R3 (p NS) after 1 year. Younger age, male sex, and higher levels of preoperative and postoperative plantar sweating were predictors of failed sympathicotomy. Increased age was associated with increased CH. Conclusions. R2 and R3 sympathicotomy for massive palmoplantar hyperhidrosis are highly effective, with low recurrence and incidences of severe CH. R2 tends to have a higher level of CH vs R3, and a higher incidence of dramatic failures is suggested in R3 patients, for which reoperation at the R2 level will likely be curative. (Ann Thorac Surg 2011;92:2015 9) 2011 by The Society of Thoracic Surgeons Classic palmar hyperhidrosis is a unique diagnosis within the broad and nondescript classification of hyperhidrosis and exists in almost all patients in its palmoplantar form [1]. Preliminary studies suggest this is an autosomal-dominant disorder with variable penetrance localized to chromosomes 14 or 5, or both [2 4]. Although notable exceptions occur, the typical form of palmoplantar hyperhidrosis has four unique characteristics: massive palmar sweating to the point of dripping or near dripping, severe sweating of the soles of the feet, bimodal onset in childhood or puberty (or exacerbation at puberty), and severe provocation of the sweating with ordinary hand lotion [1, 5, 6]. Massive palmar sweating clearly has a disabling effect on patients professional and social lives [7], and sympathetic thoracoscopic intervention appears to be superior to medical management in definitively curing patients of the disorder [1, 6, 8, 9]. However, controversy and important unanswered questions remain about what Accepted for publication July 21, Address correspondence to Dr Baumgartner, Warner Ave, #101-A, Fountain Valley, CA 92708; f.baumgartner@earthlink.net. constitutes the best sympathetic procedure for a given situation. One such controversy is the question of the specific level of the sympathetic intervention. We wished to address whether sympathicotomy over the second (R2) or third (R3) costal head was superior for patients in efficacy and in limiting side effects. Patients with debilitating palmar hyperhidrosis were enrolled into a prospective, randomized trial designed to gain insight into this question. Specifically, we wished to test the hypotheses that R2 sympathicotomy may be more reliable and may also result in increased compensatory hyperhidrosis (CH) compared with sympathicotomy at the R3 level. Material and Methods A total of 121 consecutive patients with the classic manifestations of disabling palmoplantar hyperhidrosis [6] were prospectively randomized to R2 or R3 sympathicotomy. These manifestations included massive palmar sweating to a dripping or near-dripping level, similar level of plantar sweating, onset in early childhood or puberty, and provocation with ordinary hand lotion by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur

2 2016 BAUMGARTNER ET AL Ann Thorac Surg SYMPATHICOTOMY FOR PALMAR HYPERHIDROSIS 2011;92: Table 1. Patient Demographics for R2 vs R3 Sympathicotomies Variable a R2 Group R3 Group Patients Age, years Sex Female Male Race Asian White Hispanic Other 3 2 a Continuous data are mean standard deviation; categoric data expressed as number. Random allocation was used to assign patients to an R2 or R3 intervention. The demographics of the R2 and R3 groups are tabulated in Table 1, without statistical differences identified between the populations. These 121 patients had bilateral procedures (ie, 2 sympathicotomies per patient) for a total of 142 procedures (122 R2 and 120 R3). The surgical techniques were as previously described [10]. Simple electrocautery was used to perform a single sympathicotomy transection per side at the R2 or R3 level. In all cases, an active search was performed for any accessory nerves of Kuntz which, if found, were severed. Patients were questioned at 6 months and after 1 year by phone or mail survey. Continuous variables of levels of palmar, plantar, axillary, and CH sweating were on a subjective patient-rated scale of 0 to 10. The patient scale estimates were assessed using landmarks of 0, no sweating; 5, moderately uncomfortable sweating; and 10, severe dripping sweating with significant discomfort and interference with daily activities. These variables were assessed preoperatively and at 6 months and 1 year or more. The Wilcoxon rank sum test was used for differences in continuous variables between sympathicotomy groups. The Pearson 2 test with Yates continuity correction was used for differences in dichotomous outcomes. Logistic regression analysis was used to analyze multiple category exposures. The study design and subject informed consent form were reviewed and approved by the Doctors Surgery Center Institutional Review Board. The patients frequently were treated with medical management before they sought consultation for surgical consideration. This consisted of one or more of the following: prescription or over-the-counter topical aluminum chloride, oral anticholinergics, antidepressants, sedatives, -blockers, iontophoresis, and Botulinum toxin A (Botox, Allergan Inc, Irvine, CA) injections. For those patients without prior medical treatments and whose insurance carriers so required, we initiated topical aluminum chloride hexahydrate 20% (Drysol, Person & Covey, Glendale, CA) or 6.25% (Xerac AC, Person & Covey) in anhydrous ethyl alcohol, oral glycopyrrolate (Robinul, Shionogi USA Inc, Florham Park, NJ) at progressively increased dosages, or iontophoresis with the Drionic device (General Medical, Los Angeles, CA), despite the realization that these medical treatments would likely fail. Surgical candidates were then randomized to R2 or R3 sympathicotomy after informed consent. Results All operations were done as outpatient procedures, and no complications developed, including Horner syndrome, bleeding, pneumothorax, or infection. Table 2 depicts satisfaction rating for individual sympathicotomy procedures at 6 months and at 12 or more months. More than 90% of both R2 and R3 patients were very satisfied with the procedure at 6 months and after 12 months. For R2 procedures, the lesser levels of satisfaction were primarily a result of CH. For R3 procedures, lesser levels of satisfaction were primarily due to recurrence of the palmar sweating. Recurrence of Palmar Hyperhidrosis/Procedure Failure Unilateral or bilateral extremity surgical failures occurred in 5 of 121 patients (4.1%), with recurrent palmar sweating developing to a bothersome level. This included 5 of 120 (4.2%) R3 sympathicotomy failures, and 5 of 122 (4.1%) R2 failures. There was no overall statistically significant difference in overall failure rate between R2 and R3 levels. Four of these 6 patients were considered to have truly dramatic failures of their sympathicotomy procedures with dripping palmar sweat postoperatively or requiring Robinul for palliation, or both. The dramatic failures in these 4 patients included 5 of 120 (4.2%) R3 procedures and 2 of 122 (1.6%) R2 procedures (p NS). Details of the 6 patient failures are reported in Table 3. Failures were bilateral in 4 patients and unilateral on the right side in 2 patients. The failures in R2 patients were overall less severe and took longer to recur than the more fulminant R3 failures. R3 patients 1 and 2, with failures involving 3 extremities, underwent reoperation, this time with an R2 sympathicotomy, leading to curative results at the 1-year follow-up. These three redo sympathicotomies were not included as separate R2 procedures in the data analysis. Table 2. Satisfaction Rating at 6 Months and After 1 Year for T2 and T3 Sympathicotomies R Group No. Very Satisfied Moderately Satisfied Dissatisfied R2 6 months (91.9) 3 (8.1) 0 (0) 1 year (90.2) 4 (9.8) 0 (0) R3 6 months (94.6) 0 (0) 2 (5.4) 1 year (95.0) 1 (2.5) 1 (2.5)

3 Ann Thorac Surg BAUMGARTNER ET AL 2011;92: SYMPATHICOTOMY FOR PALMAR HYPERHIDROSIS Table 3. Sympathicotomy Failures Occurring in 6 Patients Pt Level/Failure Age Sex Race Pre-op Dripping Post-op 2017 Time to Recurrence T3 1 a Bilateral 15 M Hispanic 1 week 2 a Right 20 F White Several weeks 3 b Bilateral 21 F White Few months T2 4 b Bilateral 19 M White 1 year 5 Right 21 M Hispanic 2 months 6 Bilateral 22 M Asian 6 12 months a Underwent successful redo sympathicotomies at the T2 level. b Received oral Robinul for management of palmar hyperhidrosis. The 6 patients whose hyperhidrosis was not cured were significantly younger than those patients whose sympathicotomies were completely curative ( vs years; p 0.04). There was no statistically significant difference in sympathicotomy failure rate with regard to sex, race, and extent of CH. Most of the patients with recurrences of palmar sweating were white, but the small sample size did not reach statistical significance. The univariate variables predicting sympathicotomy failures for the 121 patients and 242 procedures are listed in Table 4. The statistically significant factors predicting sympathicotomy failures on univariate analysis for the 121 patients and 242 procedures include younger age and failure of sympathicotomy to significantly help the feet. In addition, a higher level of preoperative feet sweating predicted failure in the 242 procedures. Variables predicting failure of sympathicotomy on multivariate logistic regression analysis for the 242 procedures included younger age (p 0.01), male sex (p 0.02), and more severe preoperative plantar sweating level (p 0.005). No significant variables were identified on multivariate analysis to predict failures in the 121 patients. Compensatory Hyperhidrosis The level of CH ranked on a severity scale of 0 to 10 trended toward a higher level for R2 compared with R3 sympathicotomies at 6 months and after 1year. The severity scale at 6 months was (n 38) for R2 vs Table 4. Univariate Analysis of Variables Predicting Failure for 121 Patients Undergoing 242 Sympathicotomy Procedures Variable a Success b Failure c 121 Patients p Value 242 Procedures Age, years Plantar sweating level Pre-op NS 0.05 Post-op a Data are presented as mean standard deviation. b Defined as dry palms postoperatively. c Defined as dripping, wet, or moist palms postoperatively (n 36) for R3 (p NS). Similarly, at more than 1 year, the severity scale was (n 43) for R2 vs (n 37) for R3 (p 0.09). The chance that at least some mild or significant CH would occur was generally higher in the R2 than in the R3 group (75.5% vs 58%; p NS; Table 5). However, the incidence of this causing some interference with life was much less for both groups (32% for R2 vs 19.6% for R3 procedures; p NS). The chance of significant interference with life was equally low (2%) for both R2 and R3 groups, and no patient regretted the procedure. Any significant bother or interference with life after sympathicotomy was generally far less problematic than the disabling level of the original palmar hyperhidrosis, and nearly all of the patients were very satisfied. The only dissatisfied patients were the R3 patients whose original palmar sweating returned. Univariate analysis showed increased age was associated with increased CH at 6 months (p 0.014) but not at more than 1year. On multivariate analysis, no variable predicted CH at 6 months or after 1 year. Soles of Feet and Axillae At more than 6 months, the subjective change in plantar sweating before and after sympathicotomy was similar for the R2 and R3 levels, with roughly half of sympathi- Table 5. Extent of Compensatory Hyperhidrosis Bother and Interference With Life in R2 vs R3 Sympathicotomies at More Than 6 Months Extent of CH No. None Mild Significant Bother R (24.5%) a 36 (67.9) 4 (7.6) R (42.0) a 26 (52.0) 3 (6.0) Interference with life R (68.0) b 15 (30.0) 1 (2.0) R (80.4) b 8 (17.4) 1 (2.2) a Extent of CH bother described as none R2 vs R3: p b Extent of CH interference with life described as none R2 vs R3: p CH compensatory hyperhidrosis.

4 2018 BAUMGARTNER ET AL Ann Thorac Surg SYMPATHICOTOMY FOR PALMAR HYPERHIDROSIS 2011;92: cotomies in each group resulting in improvement. In both the R2 and R3 groups, there was a 4% incidence of worsening of the plantar sweating after sympathicotomy. At more than 6 months, axillary sweating trended toward improvement more often in patients undergoing R3 procedures (19 of 44 [43%]) compared with R2 procedures (13 of 49 [26.5%]; p NS). Comment Much conflicting opinion exists about the appropriate level and extent of sympathetic intervention for patients with severe palmoplantar hyperhidrosis. Determining the level of the sympathetic intervention, whether R1, R2, R3, or R4, or a combination, and whether a sympathicotomy or sympathectomy (including the ganglion) should be done, fundamentally depends on answering two questions: treatment efficacy and incidence of undesirable side effects, particularly CH. Although earlier sympathectomy trials included the lower third of T1 (stellate ganglion), this led to an unnecessary risk of Horner syndrome because the T2 ganglion has the primary sympathetic input to the palms [11 15]. Nonetheless, some investigators have suggested that including the T2 level increases the risk of severe CH [16 19], with some even suggesting avoiding T2 altogether for palmar hyperhidrosis. Neumayer and colleagues [20] compared T2 to T4 sympathectomy with clipping the sympathetic trunk above and below the T4 ganglion. CH was significantly reduced; however, the efficacy resulting in completely dry hands was also significantly reduced. Whether these effects were due to the level itself or to the extent of resection is unclear. Chang and colleagues [21] found that sympathectomy at T2, T3, or T4 yielded comparable improvement of palmar hyperhidrosis, but that the incidence of CH from T4 sympathectomy was less than compared with the T2 level, and the severity was also less when comparing T4 to T2 or T3. In reality, their sympathectomies were sympathicotomies above and below different rib levels (ie, a T2 sympathectomy was a sympathicotomy over R2 and R3). It is unclear if the patients were classic palmoplantar hyperhidrosis cases. In Yazbek and colleagues [22] prospective, randomized trial, T2 (n 30) was compared with T3 (n 30) sympathectomy (ganglion ablation) for palmar hyperhidrosis. During the relatively short follow-up, all patients in the T2 group were cured, but dramatically recurrent hyperhidrosis developed in 1 T3 patient, and reoperation at the same T3 level did not resolve the problem. In our study, R3 sympathicotomy failures tended to be more dramatic and earlier in onset than the R2 failures, complementing Yazbek and colleagues results. Redo R2 sympathicotomies for 2 patients with R3 failures were curative. Our study further showed that sympathicotomy failures were statistically more prevalent in younger patients. The follow-up of patients in our study was relatively short but appears to have been sufficient to detect the early and florid failures that rarely occur after sympathectomy. Such dramatic failures are likely different from hyperhidrosis recurrences that are generally less florid and later in onset than true failures of the procedure itself. Yazbek and colleagues noted that there appeared to be a higher degree of severity of CH in the T2 group, but not disablingly so. Jaffer and colleagues [16], Dewey and colleagues [17], and Reisfeld [18, 19] have claimed that including T2 increases the incidence of serious CH and patient dissatisfaction. In these patient series, however, the T2 sympathetic interventions were done for facial hyperhidrosis, and sympathectomy for palmar hyperhidrosis was done at lower levels, generally avoiding T2. Thus, because the level of sympathectomy was always decided by the location of the primary hyperhidrosis, it is likely that the location of the primary hyperhidrosis may be a more important determinant of severe CH and patient dissatisfaction rather than the level of sympathectomy per se [23]. Interestingly, Dewey and colleagues study [17] reports the increased severity of CH and patient dissatisfaction with T2 sympathectomy, except in those patients who also had the procedure for palmar hyperhidrosis. Further, Reisfeld states that the alarming incidence of dissatisfaction and severe CH with sympathectomy for facial hyperhidrosis/blushing and axillary hyperhidrosis, which often does not include T2, actually precludes such operations for these cases. In a real way, it is the location of the hyperhidrosis rather than the level of resection that may be the most important, because craniofacial sweating and blushing and axillary hyperhidrosis are completely different disease forms than the classic, familial palmoplantar hyperhidrosis, and the entities have different management strategies. In our study, sympathicotomy at the R2 level trended toward a higher incidence of CH than at the R3 level, but generally not in a disabling manner. Older age was associated with worse CH on univariate and multivariate analysis. Because younger patients also exhibited a statistically higher sympathicotomy failure rate, it may thus be in this group of patients for whom R2 sympathicotomy may be ideally suited, particularly teenagers. The crucial point is proper patient selection. It is extremely uncommon in our experience for a patient who has classic, dripping palmoplantar hyperhidrosis to regret a successful operation because of CH. The suffering is so intense and their lifestyle, relations, and careers are so affected by the palmar sweating that they are willing to tolerate much to have it cured. The patient s perception of the sweating, both palmar and CH, is likely far more important than sympathectomy level per se, and proper patient selection cannot be overestimated. It is also worth emphasizing that the sympathetic operation should be considered a first-line treatment for truly appropriately dripping or nearly dripping classic palmoplantar patients, and that requiring patients to undergo medical treatments is not necessarily in their best interests [6, 9]. The almost self-perpetuating myth in the medical literature that sympathetic intervention should be a last resort in these patients is not sup-

5 Ann Thorac Surg BAUMGARTNER ET AL 2011;92: SYMPATHICOTOMY FOR PALMAR HYPERHIDROSIS ported and defies objective, evidence-based review. One cannot disregard the fact that different subtypes of hyperhidrosis exist and that surgical intervention has a far different role in the management of these subtypes of hyperhidrosis. In summary, R2 and R3 sympathicotomy for massive palmoplantar hyperhidrosis are both highly effective procedures with low recurrence rates and low incidences of severe, problematic CH. There is a trend toward a higher incidence of CH in R2 patients, and a suggestion of a higher incidence of dramatic failures in R3 patients, for which reoperation at the R2 level will likely be curative. The decision between sympathicotomy at the R2 or R3 level should be tailored to the patient s age and tolerance for CH vs surgical failure risk. References 1. Baumgartner FJ. Surgical approaches and techniques in the management of severe hyperhidrosis. Thorac Surg Clin 2008;18: Ro KM, Cantor RM, Lange KL, Ahn SS. Palmar hyperhidrosis: evidence of genetic transmission. J Vasc Surg 2002;35: Higashimoto I, Yoshiura K, Hirakawa N, et al. Primary palmar hyperhidrosis locus maps to 14q11.2-q13. Am J Med Genet 2006;140A: Cantor-Chiul RM, Chandra F, Dorrani N, Swatling C, Glaser D, Ahn S. Evidence of a hyperhidrosis risk gene at 5q ; Abstract #1706, Presented at the annual meeting of Am Soc Human Genetics, 10 October 2006, New Orleans, Louisiana Baumgartner FJ. Compensatory hyperhidrosis after thoracoscopic sympathectomy. Ann Thorac Surg 2005;80; Baumgartner FJ, Bertin S, Konecny J. Superiority of thoracoscopic sympathectomy over medical management for the palmoplantar subset of severe hyperhidrosis. Ann Vasc Surg 2009;23: Cetindag IB, Boley TM, Webb KN, Hazelrigg SR. Long-term results and quality-of life measures in the management of hyperhidrosis. Thorac Surg Clin 2008;18: Reisfeld R, Berliner KI. Evidence-based review of the nonsurgical management of hyperhidrosis. Thorac Surg Clin 2008;18: Ambrogi V, Camiione E, Mineo D, Paterno EJ, et al. Bilateral thoracoscopic T2 to T3 sympathectomy versus botulinum injection in palmar hyperhidrosis. Ann Thorac Surg 2009;88: Baumgartner FJ, Toh Y. Severe hyperhidrosis: clinical features and current thoracoscopic surgical management. Ann Thorac Surg 2003;76: Cloward RB. Hyperhidrosis. J Neurosurg 1969;30: Goetz RH, Marr JAS. The importance of the second thoracic ganglion for the sympathetic supply of the upper extremities with a description of two new approaches for its removal in cases of vascular disease: a preliminary report. Clin Proc 1944;3: Hyndman OR, Wolkin J. Sympathectomy of the upper extremity: evidence that only the second dorsal ganglion need be removed for complete sympathectomy. Arch Surg 1942; 45: Atlas LN. The role of the second thoracic spinal segment in the preganglionic sympathetic innervation of the human hand surgical implications. Ann Surg 1941;114: Lemmens HAJ. Importance of the second thoracic segment for the sympathetic denervation of the hand. Vasc Surg 1982;16: Jaffer U, Weedon K, Cameron AEP. Factors affecting outcome following endoscopic thoracic sympathectomy. Br J Surg 2007;83: Dewey TM, Herbert MA, Hill SL, et al. One-year follow-up after thoracoscopic sympathectomy for hyperhidrosis: outcomes and consequences. Ann Thorac Surg 2006;81: Reisfeld R. One-year follow-up after thoracoscopic sympathectomy for hyperhidrosis. Ann Thorac Surg 2007;83: Reisfeld R. The importance of classification in sympathetic surgery and a proposed mechanism for compensatory hyperhidrosis: experience with 464 cases. Surg Endosc 2007;21: Neumayer C, Zacherl J, Holak G, et al. Limited endoscopic thoracic sympathetic block fo rhyperhidrosis of the upper lim: reduction of compensatory sweating by clipping T4. Surg Endosc 2004;18: Chang YT, Li HP, Lee JY, et al. Lin PJ, Lin CC, Kao EL, Chou SH, Huang MF. Treatment of palmar hyperhidrosis: T(4) level compared with T(3) and T(2). Ann Surg 2007;246: Yazbek G, Nelson W, de Campos JRM, et al. Palmar hyperhidrosis-which is the best level of denervation using videoassisted thoracoscopic sympathectomy: T2 or T3 ganglion? J Vasc Surg 2005;42: Baumgartner F, Konecny J. Compensatory hyperhidrosis after sympathectomy: level of resection versus location of hyperhidrosis. Ann Thorac Surg 2007;84:1422.