Thoracoscopic sympathectomy has been used for

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1 Long-Term Results of Thoracoscopic Sympathectomy for Hyperhidrosis Pascal Dumont, MD, Alexandre Denoyer, MD, and Patrick Robin, MD Department of Thoracic, Cardiac, and Vascular Surgery, Unit of Thoracic Surgery, University Hospital of Tours, Hôpital Trousseau, Tours, France Background. Thoracoscopic sympathectomy is now the reference treatment for severe palmar hyperhidrosis, but this is offset by the occurrence of compensatory sweating. It has been studied in this series to improve the indications and information given to patients. Methods. A retrospective review of 124 patients who were previously afflicted with bilateral thoracoscopic sympathectomy 6 years earlier was conducted. Patients were interviewed by postal questionnaire regarding the results and side effects. Results. The series consisted of 89 females (72%) and 35 males and the mean age was 28 years. The main indication was palmo-plantar hyperhidrosis (34%). The mean operating time was 36 minutes and there were no intraoperative complications. Postoperative pneumothorax occurred in 9 patients and 3 patients required a chest drain. The hospital stay was 36 hours for 87.6% of the patients. Postoperative pain occurred in 78% of the patients. Neurologic complications (Horner syndrome, radial paralysis, and dysesthesia of the arm) occurred in 3 patients and disappeared after 2 6 months. Two patients required single-side reoperation because of failure with the first intervention. Eighty-nine replies to questionnaires were received (72%). The results for hands were favorable in 98% and in 63% for axillae. Compensatory sweating occurred in 87% of the patients (serious in 36% and incapacitating in 6%). Despite this 90% of the patients were satisfied or very satisfied. Conclusions. This study confirms that thoracoscopic sympathectomy is a suitable method of treatment for severe palmar hyperhidrosis but emphasizes the need to offer the patient more informative information, especially regarding compensatory sweating which seems inescapable. (Ann Thorac Surg 2004;78:1801 7) 2004 by The Society of Thoracic Surgeons Thoracoscopic sympathectomy has been used for many years and is now the reference treatment for severe palmar hyperhidrosis. Videothoracoscopy renders it a simple and safe procedure with a short hospital stay. The results and side effects (such as compensatory sweating) of this procedure are well recognized but vary between patients. The main problem seems to be the transfer of hypersweating from hands to trunk. The aim of this study was to analyze the results of this procedure since 1994, to identify the best indications, and to give the best preoperative information possible. Patients and Methods From June 1994 to June 2000 bilateral thoracoscopic sympathectomy was performed for hyperhidrosis in 124 patients. Eighty-nine patients were female (72%) and 35 were male (age range years, mean 28 years). An initial consultation was necessary to evaluate the personal, professional, and social handicaps related to hyperhidrosis and a preoperative chest radiograph was performed to exclude lung or pleural disorders. Information about the results and side effects of the procedure Accepted for publication Jan 9, Address reprint requests to Dr Dumont, Unité de Chirurgie Thoracique, Hôpital Trousseau, Tours Cedex, France; dumont@med. univ-tours.fr. were given during this first consultation. Information was obtained from hospital files and postal questionnaires. The questionnaire was approved by the Ethics Committee (equivalent in France to the Institutional Review Board in the USA). Indications The indications are given in Table 1. The most frequent indication was palmo-plantar hyperhidrosis (34%). There were approximately two groups of indications: the first comprised palmar indications and the second, smaller group, comprised axillary indications without sweating of the hands (last three lines of Table 1). Medical treatments such as iontophoresis were unsuccessful in 64% of the patients preoperatively. Surgical Procedure The same bilateral operation in one stage was performed for all patients [1]. The procedure was performed under general anesthesia using a double lumen endotracheal tube. The patient was placed on the operating table in a semisitting position with arms in abduction. After clamping the right side of the tracheal tube [2], the thoracoscope (8 mm 0 ; Karl Storz GmbH & Co. KG, Tuttlingen, Germany) was introduced through a 10.5 mm port in the left fifth intercostal space behind the border of the pectoralis major muscle. A second 5 mm port was introduced in the fourth intercostal space on the anterior 2004 by The Society of Thoracic Surgeons /04/$30.00 Published by Elsevier Inc doi: /j.athoracsur

2 1802 DUMONT ET AL Ann Thorac Surg SYMPATHECTOMY FOR HYPERHIDROSIS 2004;78: Table 1. Indications for Surgical Sympathectomy axillary line. The sympathetic chain was visualized running down over the necks of the ribs and was sectioned with scissors at the level of the lower border of the first rib. Diathermy was not used before this time to avoid electrical lesions of the stellae ganglia. After section of the sympathetic chain, the mediastinal pleura was vertically incised by diathermy and the sympathetic chain was dissected and removed from the second to the fourth ganglion (Fig 1). Collateral nervous trunks were coagulated. A chest drain was used until the end of the operation. The same procedure was performed for the right side and then chest drains were removed. A chest radiograph was performed in the recovery room immediately after surgery, at 6 hours, and then again just before discharge. Patients were followed up 1 month postoperatively and a chest radiograph was performed. Questionnaire A postal questionnaire (see Appendix) was sent to 124 patients in January It was comprised of two parts: the first part concerned itself with the side effects that occurred after hospitalization (pain, compensatory sweating, etc) and the second part concerned itself with the local long-term results, consequences regarding personal and professional life, hobbies, and overall evaluation. Pain was evaluated on a scale of 0 10 (0 none, 5 moderate, 10 very severe). Results Eighty-nine replies to the questionnaire were received (72%). Twenty were returned because of the change of address and 15 patients were not identified. The interval between surgery and the response to the questionnaire was 6 78 months (average 36 months, standard deviation 20.39). The average time of operation was 36 minutes (average 15 70). The length of hospital stay was 1.5 days (36 hours) for 106 patients (87.6%), 2.5 days for 12 patients, 4 days for 2 patients, and 5 days for 1 patient. The Fig 1. The sympathetic chain is dissected and removed from the second to the fourth ganglion. mean interval between discharge and return to work was 12 days. There were no intraoperative complications. Postoperative chest radiographs illustrated minor unilateral pneumothorax in 9 patients that required draining for 6 24 hours in only 3 patients (2.4%). Neurologic complications occurred in 3 patients (ie, Horner syndrome which disappeared after 3 months, radial paralysis which disappeared after 6 months, and dysesthesia of the arm which disappeared after 6 months). Pain after hospitalization occurred in 78% of the patients. The pain was moderate in 27% of the patients, severe in 34% of the patients, and very severe in 17% of the patients. Anterior chest pain as after thoracotomy Table 2. Results According to Replies to Questionnaire Hands Axillae Feet Completely dry 92% 24% 2% Visible improvement 6% 39% 16% Minimal improvement 1% 6% 16% No change 0% 2% 29% No reply or unnecessary (normal sweating before procedure) 1% 29% 37%

3 Ann Thorac Surg DUMONT ET AL 2004;78: SYMPATHECTOMY FOR HYPERHIDROSIS 1803 Table 3. Compensatory Sweating According to Replies to Questionnaire Level of Compensatory Sweating No. of Patients % None Low 6 7 Moderate Severe Very severe 5 6 Total was reported in 39% of the patients, upper back pain was reported in 17% of the patients, anterior chest and upper back pain (both locations) was reported in 9% of the patients, and there was no information regarding the location of the pain in 13% of the patients. Anterior chest pain was less severe than upper back pain (average 6.2 vs 7.6) but more long lasting (average 9.8 weeks vs 8.5 weeks). Pain was controlled by level 2 analgesics (codeine, propoxyphene alone, or in combination with acetaminophen) according to the World Health Organization classification. All but 2 patients experienced dry hands postoperatively. Two patients required single-sided reoperation because of failure on one side during the first operation (2 days postoperatively for 1 patient and 3 months postoperatively for the other patient). The results regarding hyperhidrosis are presented in Table 2. Oddly there was an improvement regarding the feet in 34% of the patients. These results have been stable since 1995 except for 1 patient who experienced increased sweating of one hand. The average interval postoperatively was 36 months (6 78 months). Compensatory sweating occurred in 77 (87%) of the 87 respondents. The locations and levels of compensatory sweating are summarized in Tables 3 and 4. This side effect did not change over time. Precipitating factors included heat (43%), emotion or stress (33%), and physical activity (22%). Patients reported one (17%), two (34%), or three (4%) precipitating factors, however they were not specified in 25% of the questionnaires. Four Table 4. Location of Compensatory Sweating patients (4%) experienced constant compensatory sweating without any precipitating factors and 3 patients (3%) indicated increased plantar sweating. In addition other side effects were reported. These included hand dryness with cracking which occurred in 6 patients (5%) and gustatory sweating activated by spices or chocolate which occurred in 5 patients (4%). Results for the palmar group and the axillary group for all respondents are summarized in Table 5 Comment Thoracic sympathectomy is a well-established treatment for hyperhidrosis but it is an empiric treatment. The results are unpredictable and vary between patients. It thus seemed important to establish the long-term results and side effects. To do this several questions had to be asked. There were a favorable percentage of replies (72%) to our study based on a postal questionnaire. The advantage of this kind of questionnaire is that it allows patients freedom from medical influence, but the disadvantage is the risk of not obtaining replies from dissatisfied patients. This negative effect was taken into account for both groups (palmar and axillary, Table 5). First, compensatory sweating seems to occur after sympathectomy in most cases. Is it therefore reasonable to remove one disorder to create another? In our series compensatory sweating occurred in 87% of the patients. This is of the same order as in other recent series: sometimes it is as high as 90% as in the study by Fredmann and associates [3] or 88% as in the study by Lin and associates which involved 2200 patients [4] and sometimes it is lower at 67% as in the study by Zacherl and associates [5], 86.4% in the study by Gossot and associates [6], and 59.8% as in the study by Rex and associates [7]). Fortunately this side effect is most often moderate and well tolerated by patients. According to results of the questionnaires 90% of the patients were satisfied and 98% of the patients experienced improved quality of life. It seems to be the level of severe compensatory sweating (6% in our study) that is more important and is also reported by several authors (2%, Lin and associates [4], 3%, Leseche and associates [8], and 7.5%, Gossot and associates [6]) than the overall rate of compensatory sweating. However the definition of severe compensatory sweating has not been clearly established and the evaluation of quality of life by the patient is a suitable way of estimating the results. Compensatory sweating is not a complication but rather the consequence experienced for dry hands. In our study compensatory sweating was most often moderate and well tolerated by patients who said that sweating of the trunk is easier to manage that sweating of the hands. However it is very important to inform patients of this side effect before any procedure is performed and to verify that it is understood. It is also necessary to inform patients about other complications. One way to avoid this situation may be to use the clamping method (sympathetic block by clipping). There have been several interesting studies involving this technique [9, 10]. The clamping method

4 1804 DUMONT ET AL Ann Thorac Surg SYMPATHECTOMY FOR HYPERHIDROSIS 2004;78: provides the same rate of success and the same rate of compensatory sweating but with the potential for reversal in those patients who are unhappy because of severe compensatory sweating. However experience with reversal is still fairly limited. Second, we hoped to establish whether our indications were appropriate and whether we would have to make any changes or accommodations in the future. Our results were fairly favorable with the same sympathetic trunk resection whatever the indication, but less favorable in the axillary group. Review of the literature also indicates that axillary indications are not as successful as palmar indications [6, 7] particularly in the Japanese national study (Ueyama and associates [11]) involving 7017 patients. We therefore studied patients in two groups according to these indications. The best results were presented in the palmar group (where the palmar hyperhidrosis was the main symptom) with a level of satisfaction of 93% and improvement in quality of life of 100%. This was not the case in the other group in which axillary hyperhidrosis was the main symptom. The number of replies to the questionnaire was lower (66%) in this group and only 67% of the patients were satisfied. Moreover there were patients without improvement in this group, patients with poorer quality of life, and fewer replies concerning overall appreciation. This result confirms findings reported in the literature that the compensatory sweating is dependent upon the height of the sympathetic chain resection. Compensatory sweating is greater with T2 T4 resection than with T2 or T3 only or T2 T3 resection. With resection of only T3, van t Riet and associates [12] reported 0% compensatory sweating and Yoon and associates [13] reported 3.7% mild compensatory sweating. Tan and associates [14] compared T2 only versus T2 T4. He also reported 0% compensatory sweating in the T2 group. Lin and associates [4] resected T2 for the palmar group and T3 T4 for the axillary group. Severe compensatory sweating was more frequent in the second group (2% vs 5%). On the other hand numerous authors have reported that treatment of axillary hyperhidrosis requires resection as far as T4 [4, 7, 15]. Finally some authors such as Leseche and associates [8] did not find any difference in the level of compensatory sweating whatever the level of resection. With only clamping of T2 Lin and associates [9] reported 83% of compensatory sweating in 52 patients. Selective sympathectomy (only the rami communicantes were divided and the main trunk respected) does not provoke compensatory sweating but unfortunately this technique is reported to be ineffective [6, 16]. One of the patients in our study had previously been operated on using this procedure in another hospital without success, but the result was favorable after reoperation. The above results do not provide a consensus regarding the most favorable technique, however according to our results and to the literature, it seems that our surgical technique is unsuitable for the treatment of axillary hyperhidrosis. Other authors such as Zacherl and associates have expressed the same opinion [5]. We currently dissuade patients with isolate axillary hyperhidrosis from Table 5. Quality of Life and Overall Evaluation Quality of Life and Overall Evaluation Series Palmar Group Axillary Group Number of patients Percentage of replies to 72% 73% 66% questionnaire Quality of life improved 98% 100% 83% No change 1% 0% 8.5% Poorer quality of life 1% 0% 8.5% Very satisfied 60% 66% 17% Satisfied 30% 27% 50% Not very satisfied 4.5% 3% 16.5% No reply 5.5% 4% 16.5% surgery and propose treatment with botulinum toxin (50 U Botox per axilla; Allergan, Inc, Irvine, CA). It would seem that botulinum toxin is the best indication for the treatment of hyperhidrosis [17]. Botox treatment is effective and does provide a reduction of sweat secretion [18]. Consequently there is no compensatory sweating but there are three drawbacks: intradermal injections are rather painful, the mean duration of benefit is only 7 months, and the cost of the toxin in France is covered by the patient ($ $300.00). However it does seem possible to operate for isolated axillary hyperhidrosis if the patient is very determined and fully informed about the side effects, perhaps by using limited T4 T5 resection as described by Hsu and associates [15] who indicated 86% excellent or good results and only 29% compensatory sweating. However Lin [19] used T3 T4 sympathetic blocking by clips and indicated 92% satisfaction and 88.5% compensatory sweating. Furthermore Fredmann and associates [3] have reported similar results. Nevertheless clips can, of course, be removed if patients are unhappy about severe compensatory sweating. In our opinion surgical sympathectomy is currently the most suitable treatment for palmar hyperhidrosis. According to the literature resection of the sympathetic trunk can be reduced to T2 T3 in isolated palmar hyperhidrosis to decrease the risk of compensatory sweating. Drawbacks have been reported for injections of botulinum toxin to palms, as they are very painful and require sufficient anesthesia. There may be hand paresthesia for 1 month after injections whereas the benefit only lasts a few months. Finally it is imperative to ponder what developments are possible in the future? Our initial technical choices were motivated by the use of the same procedure as other types of videothoracoscopy (double lumen endotracheal tube, two endoscopic ports, 8 mm thoracoscope, etc). However literature reports would suggest that we change this procedure. For instance, the reduction of postoperative pain is a challenge. This complication is rarely mentioned in the literature possibly because it was transient. The pain mainly reported in our series was anterior chest pain, in keeping with intercostal trauma by the 10.5 mm port. We will now use a5mm0 thoracoscope instead of 8 mm to decrease intercostal trauma. We

5 Ann Thorac Surg DUMONT ET AL 2004;78: SYMPATHECTOMY FOR HYPERHIDROSIS 1805 have tried a 2 mm thoracoscope but the visibility was limited and it was too fragile. It seems to us that decreasing local electrocauterization decreases the intensity of postoperative upper back pain. Fredmann and associates [3] reported 12% persistent postoperative chest pain using a diathermy probe. Lin and associates [4] suggested that the lesion of the rib periosteum below the sympathetic chain was a possible cause of postoperative pain. This study confirms our choice and preference to operate for severe and dominant palmar hyperhidrosis. Though the risks of this type of surgery are rather minimal, we do not operate for minor forms of palmar hyperhidrosis. For isolated palmar forms we restrict the height of resection of the sympathetic trunk to only the T2 T3 ganglions. We also restrict coagulation as much as possible and will change the port (5 mm instead of 8 mm) that seems to be the origin of postoperative pain. Despite the main drawback of compensatory sweating, surgical sympathectomy remains a favorable treatment for severe and dominant palmar hyperhidrosis because it manifestly improved the quality of life for patients in our series. Our role is to select indications carefully and to provide informative and thorough information to patients. References 1. Dumont P, Hamm A, Skrobala D, Robin P, Toumieux B. Bilateral thoracoscopy for sympathectomy in the treatment of hyperhidrosis. Eur J Cardio-Thor Surg 1997;11: Dumont P, Hamm A, Parenti JL, et al. Etude de la PaO 2 au cours des vidéothoracoscopies bilatérales pour sympathectomies. J Chir Thor Cardiovasc 1998;4:156 7 (abstract). 3. Fredmann B, Zohar E, Shachor D, Bendahan J, Jedeikin R. Video-assisted transthoracic sympathectomy in the treatment of primary hyperhidrosis: friend or foe? Surg Laparosc Endosc Percutan Tech 2000;4: Lin TS, Wang NP, Huang LC. Pitfalls and complication avoidance associated with transthoracic endoscopic sympathectomy for primary hyperhidrosis (analysis of 2200 cases). Int J Surg Investig 2001;2: Zacherl J, Huber ER, Imhof M, Plas EG, Herbst F, Fugger R. Long-term results of 630 thoracoscopic sympathicotomies for primary hypehidrosis: the Vienna experience. Eur J Surg Suppl 1998;580: Gossot D, Galetta D, Pascal A, et al. Long-term results of endoscopic thoracic sympathectomy for upper limb hyperhidrosis. Ann Thorac Surg 2003;75: Rex LO, Drott C, Claes G, Göthberg G, Dalman P. The Borås experience of endoscopic thoracic sympathicotomy for palmar, axillary, facial hyperhidrosis and facial blushing. Eur J Surg Suppl 1998;580: Leseche G, Castier Y, Thabut G, et al. Endoscopic transthoracic sympathectomy for upper limb hyperhidrosis: limited sympathectomy does not reduce postoperative compensatory sweating. J Vasc Surg 2003;37: Lin TS, Huang LC, Wang NP, Lai CY. Video-assisted thoracoscopic T2 sympathetic block by clipping for palmar hyperhidrosis: analysis of 52 cases. J Laparoendosc Adv Surg Tech A 2001;11: 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: Ueyama T, Matsumoto Y, Abe Y, Yuge O, Iwai T. Endoscopic thoracic sympathicotomy in Japan. Ann Chir Gynaecol 2001; 90: van t Riet M, de Smet AA, Kuiken H, Kazemier G, Bonjer HJ. Prevention of compensatory hyperhidrosis after thoracoscopic sympathectomy for hyperhidrosis. Surg Endosc 2001; 10: Yoon DH, Yoon H, Park YG, Chang JW. Thoracoscopic limited T3 sympathicotomy for primary hyperhidrosis: prevention for compensatory hyperhidrosis. J Neurosurg 2003; 99: Tan V, Nam H. Results of thoracoscopic sympathectomy for 96 cases of palmar hyperhidrosis. Ann Thorac Cardiovasc Surg 1998;5: Hsu CP, Shia SE, Hsia JY, Chuang CY, Chen CY. Experiences in thoracoscopic sympathectomy for axillary hyperhidrosis and osmidrosis: focusing on the extent of sympathectomy. Arch Surg 2001;10: Gossot D, Toledano L, Fritsch S, Célérier M. Thoracoscopic sympathectomy for upper limb hyperhidrosis: looking for the right operation. Ann Thorac Surg 1997;64: Naumann M, Hamm H. Treatment of axillary hyperhidrosis. Br J Surg 2002;89: Nauman M, Lowe NJ. for the Hyperhidrosis Clinical Study group. Botulinum toxin type A in treatment of bilateral primary axillary hyperhidrosis: randomized parallel group, double blind, placebo controlled trial. Br M J 2001;323: Lin T.S. Endoscopic clipping in video-assisted thoracoscopic sympathetic blockade for axillary hyperhidrosis. An analysis of 26 cases. Surg Endosc 2001;15:126 8.

6 1806 DUMONT ET AL Ann Thorac Surg SYMPATHECTOMY FOR HYPERHIDROSIS 2004;78: Appendix Hypersweating Questionnaire

7 Ann Thorac Surg DUMONT ET AL 2004;78: SYMPATHECTOMY FOR HYPERHIDROSIS 1807 Appendix (Continued).