Thoracoscopic Sympathectomy for Hyperhidrosis: Indications and Results

Thoracoscopic Sympathectomy for Hyperhidrosis: Indications and Results Neelan Doolabh, MD, Shannon Horswell, Mary Williams, ANP, Lynne Huber, RNFA, Syma Prince, RN, BSN, Dan M. Meyer, MD, and Michael J. Mack, MD University of Texas Southwestern Medical Center at Dallas, CRSTI, Medical City Hospital, Dallas, Texas Background. Hyperhidrosis can cause significant professional and social handicaps. Although treatments such as oral medication, botox, and iontophoresis are available, surgical sympathectomy is being increasingly utilized. Methods. Between January 1997 and December 2002, 180 patients with palmar, axillary, facial, or plantar hyperhidrosis underwent a thoracoscopic sympathectomy. Surgical technique evolved during our study period and included excision of the sympathetic ganglia at T 2,T 3,orT 4 depending on the location of the sweating using monopolar cautery. Results. Patient demographics included 33% males (59/180) and 67% females (121/180), with a mean age of 29.2 years old (range 12 to 76 years old). Ethnic origin was 67% white (122/180), 19% Asian (34/180), 8% Black (14/ 180), and 6% Hispanic (10/180). Positive family history of hyperhidrosis was noted in 57%. Preoperatively, 49% patients (86/180) had palmar sweating only, 7% patients (12/180) axillary only, 24% patients (43/180) palmar and axillary, 16% patients (28/180) face/scalp only, and 7% patients (11/180) all of the above; additionally 69% patients (125/180) had plantar hyperhidrosis. All procedures were performed through 3-mm and 5-mm ports, and 98% (177/180) were completed as an outpatient procedure. Complications included a mild temporary Horner s Syndrome (n 1; 0.5%), air leak requiring chest drainage (n 9; 5%), and bleeding (n 3; 1.6%) requiring thoracoscopic reexploration (n 1) and chest drainage (n 2). Success rates were palmar 100% (109/109), axillary 98% (48/49), and face/scalp 93% (26/28). Plantar hyperhidrosis responded with improvement in 82% (72/88) of all patients. Seventy-eight percent patients (96/123) experienced compensatory hyperhidrosis, usually affecting the stomach, chest, back, and neck. Overall satisfaction was 94% (139/148). Conclusions. Thoracoscopic sympathectomy is a safe and effective outpatient method for managing hyperhidrosis. Although overall satisfaction is high, patients should be fully informed about the potential for compensatory sweating. (Ann Thorac Surg 2004;77:410 4) 2004 by The Society of Thoracic Surgeons Presented at the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31 Feb 2, 2003. Address reprint requests to Dr Doolabh, 4511C Bowser Ave, Dallas, TX 75219; e-mail: nsdoolabh@aol.com. Hyperhidrosis is an idiopathic condition characterized by excessive sweating occurring in up to 1% of the population, with an apparent increased prevalence in countries of the Far East [1]. Hyperhidrosis most commonly occurs spontaneously, or in response to temperature and emotional changes, or as a result of increased sympathetic activity [2]. Secondary causes include central nervous system conditions such as disorders of the hypothalamus or pituitary glands, or chronic diseases such as tuberculosis, lymphoma, diabetes, thyrotoxicosis, or pheochromocytomas. The areas of the body commonly affected in hyperhidrosis in order of frequency include the palms, feet, axilla, head, or face. These symptoms usually begin in childhood or adolescence, often representing an incapacitating and embarrassing disorder that can interfere with social and professional activities. Early surgical management for hyperhidrosis required an open thoracotomy. This was accompanied by a prolonged recovery period and significant morbidity including Horner s syndrome [3, 4]. However, with recent advances in video-assisted thoracoscopy, upper thoracic dorsal sympathectomy has emerged as a viable first line treatment for essential hyperhidrosis. The incidence and severity of complications following treatment with video-assisted thoracoscopy has been shown to decline, with reported incidences of Horner s syndrome ranging from 0 to 1.9% [5 11]. This study is a retrospective review of 180 consecutive patients undergoing thoracoscopic sympathectomy at our institution to analyze the indications for, success of, and safety with this modality of treatment for essential hyperhidrosis. Material and Methods Operative Technique All procedures are performed with the patient supine with their arms extended under general anesthesia with double-lumen endotracheal intubation so that the lung on the operative side can be deflated. Three separate 3-mm incisions are then made along the inframammary fold, first on the right side, through which three sealed thoracoscopic ports are placed (Fig 1). Carbon dioxide 2004 by The Society of Thoracic Surgeons 0003-4975/04/$30.00 Published by Elsevier Inc doi:10.1016/j.athoracsur.2003.06.003

Ann Thorac Surg DOOLABH ET AL 2004;77:410 4 SYMPATHECTOMY FOR HYPERHIDROSIS 411 GENERAL THORACIC Fig 1. Three 3-mm trocars placed inframammary for a 30-degree, 3-mm scope, electrocautery hook, and grasper. (CO 2 ) insufflation less than 8 mm Hg of pressure is used routinely to improve exposure of the dorsal sympathetic trunk (Fig 2). The pleural space is then inspected using a 30-degree 3-mm endoscope. The rib spaces and corresponding segment of the sympathetic chain are then visualized and the overlying parietal pleura incised. Using monopolar cautery the sympathetic ganglia at T 2, T 3,orT 4 are isolated and individually excised. In general, we excise the T 2 ganglion for patients with facial and scalp symptoms, T 3 ganglion for palmar symptoms, and the T 4 ganglion for patients with axillary hyperhidrosis. Hemostasis is then obtained and air is evacuated from the pleural space through a small-bore catheter as the ports are removed, making chest tube insertion unnecessary (Fig 3). The procedure is then repeated on the left side. A chest roentgenogram is then obtained at the completion of the procedure to confirm adequate expansion of the lungs. The patients are then observed in the recovery area and are routinely discharged within 3 hours. Fig 3. Postoperative appearance of the incisions. Data Collection Clinical charts were reviewed for patient demographic data, family history, location and duration of symptoms, and prior treatment modalities. Postoperatively patients were contacted by telephone or were sent questionnaires to assess early and late operative outcome, degree of compensatory sweating, persistent complications, and degree of satisfaction with the treatment. Results During the period between January 1997 and December 2002, 180 patients with palmar, axillary, plantar, or facial hyperhidrosis underwent video-assisted thoracoscopic sympathectomy at our institution. Complete follow-up was achieved in 100% of patients. All procedures were scheduled on an outpatient basis. Patient demographics included 59 males (33%) and 121 females (67%), mean age 29.2 years old (range 12 to 76 years old). Ethnic origin was 122 white (67%), 34 Asian (19%), 14 Black (8%), and 10 Hispanic (6%). A positive family history of hyperhidrosis was noted in 57%. Distribution of areas of the body affected are listed in Table 1. There were no deaths or major intraoperative complications. One patient developed a mild, temporary Horner s syndrome (ptosis), which resolved over a 4-month period. An air leak requiring chest tube drainage was noted in 9 patients (5%); all these patients were managed with a Heimlich valve as an outpatient. Three patients (1.6%) developed bleeding complications, one requiring thoracoscopic reexploration and two requiring tube thoracostomy. Success rates at 30 days are listed in Table 2. Plantar hyperhidrosis responded variably; however, im- Table 1. Distribution of Sweating (n 180) Fig 2. Endoscopic view of sympathetic nerve. Palms 86 (49%) Axilla 12 (7%) Palms and axilla 43 (24%) Face/scalp 28 (16%) All of above 11 (7%) Plantar in addition 125 (69%)

412 DOOLABH ET AL Ann Thorac Surg SYMPATHECTOMY FOR HYPERHIDROSIS 2004;77:410 4 Table 2. Success Rates Palmar 140/140 (100%) Axillary 54/55 (99%) Face/scalp 37/39 (95%) Plantar 72/125 (58%) proving to at least some degree in 58% of patients. Seventy-six percent of patients (84/111) experienced compensatory hyperhidrosis of varying degrees usually affecting the upper abdomen, lower back, inner aspect of the thighs, or behind the knees. The degree of compensatory hyperhidrosis in those in which it occurred was mild in 88%, moderate in 10%, and severe in 2%. An additional 3% of patients developed gustatory hyperhidrosis on the back of the neck associated with eating spicy foods. Overall satisfaction rate at 1-year follow-up was 94% (139/148). Mean follow-up is 17 months (range 0 to 60 months). There have been two recurrences of palmar hyperhidrosis, one unilateral and one bilateral, at 24 and 34 months. Comment The therapeutic options for the management of hyperhidrosis have traditionally been nonoperative. These include topical astringents, absorbing powders, and anticholinergic drugs. Other methods of treatment have included biofeedback, iontophoresis, botulinum toxin, and percutaneous phenol block. These methods seldom give sufficient relief, their effects are usually transient, and they are not without associated side effects [12]. The anticholinergics commonly cause dry mouth and blurry vision, making their long-term use undesirable. Botox (Botulinum toxin type A) is effective as treatment for axillary and palmar hyperhidrosis; however, the effects usually last only 3 to 4 months with repeated injections required. Therefore, surgical sympathectomy is assuming a larger role as primary therapy. Thoracic sympathectomy for hyperhidrosis was first described in the 1920s by Kotzareff [13]. The original approach was a two-stage procedure, which involved a dorsal paravertebral incision for access to the sympathetic chain. Since that original report, multiple open surgical approaches have been developed, most of which are associated with significant morbidity. The approaches included the anterior supraclavicular [14], posterior paravertebral [15], posterior midline [16], anterior thoracic [17], axillary thoracic [18], and the axillary extrathoracic with first rib resection [19]. Acceptance of surgical sympathectomy for hyperhidrosis proved limited as the risks of surgery were thought to outweigh the potential benefits in this benign condition. Kux advocated an endoscopic technique as early as 1954 [6]. Recent advancements in videooptics and specialized instrumentation have significantly facilitated sympathectomy. The sympathetic trunk can be easily identified through the parietal pleura thoracoscopically and surgical division of the trunk can be safely performed with minimal associated morbidity. Table 3. Compensatory Hyperhidrosis After Sympathectomy Author Number of Patients Technique Percent Compensatory Zacherl [8] 352 Transection 69.0% Gossot [10] 940 Transection/excision 86.4% Hsia [25] 47 Excision 74.5% Lin, T-S [12] 1140 Excision 84.0% Lin, C-L [26] 71 Ablation 84.8% Present series 180 Excision 76.0% Our operative technique has evolved with experience. A few points are worth noting. First, downsizing trocars to 3 mm has significantly diminished postoperative pain (even compared with 5-mm ports). Typical postoperative analgesic requirements are two to four propoxyphene tablets in the first 24 to 48 hours only. Second, although the procedure can be performed through open ports without CO 2 insufflation, the addition of CO 2 pressure markedly enhances visualization by displacing the lung and expediting the procedure. Similarly, use of a double lumen endotracheal tube, although not necessary, is a major facilitating aspect. Third, elimination of postoperative chest drainage has proven to be safe and less painful and expedites recovery. Any intrathoracic air leak is immediately apparent at closure and can be easily managed by a catheter placed to a Heimlich valve. Removal is usually possible within 1 to 24 hours. This method of air leak management has been sufficient in all patients. The excellent view of the ganglion, together with adequate magnification, allows for precise division of the ganglion, which results in lower incidences of Horner s syndrome (0.4% to 2.4%) when compared with open sympathectomy [8, 10, 11, 20]. In our series only 1 patient (0.55%) developed a temporary Horner s syndrome. Other complications, including air leak requiring chest drainage and bleeding, were relatively uncommon in accordance with other series [8, 10, 11, 20 23]. Seventy-six percent of our patients experienced compensatory hyperhidrosis, usually affecting the upper abdomen, lower back, inner thighs, and behind the knees. Other series have reported compensatory hyperhidrosis occurring in between 67% and 85% of their patients (Table 3) [24 27]. The incidence and degree of compensatory sweating appear to depend on the extent of resection of the sympathetic chain, which may account for the differences in various series. Our technique involves limited excision of the ganglia at T 2, T 3, or T 4 depending upon the patient s symptom complex. Only the level necessary for response (T 2 for face/scalp, T 3 for hands, T 4 for axilla) is excised to minimize compensatory symptoms. Methods described for performing sympathectomy include simple transection of the sympathetic ganglion, ablation with cautery or laser, or simple clipping of the sympathetic chain with titanium clips. Clipping of the sympathetic chain, without division or ablation, allows the theoretical advantage of reversal should

Ann Thorac Surg DOOLABH ET AL 2004;77:410 4 SYMPATHECTOMY FOR HYPERHIDROSIS Table 4. Results in Sympathectomy Author Number of Patients Transection Percent Palms Percent Feet Percent Axilla Percent Face Reisfeld [27] 354 Clamping 100% 85% 78% 94% Reisfeld [27] 305 Excision 100% 80% 80% 88% Lin, T-S [12] 1360 Excision 99% 64% Zacherl [8] 630 Transection 95% 68% Goh [20] 35 Ablation 97% Fox [24] 55 Transection 100% 91% Present series 180 Excision 100% 58% 99% 95% 413 GENERAL THORACIC the symptoms of compensatory sweating become unbearable. In our experience, the desire for reversibility is rare (2 patients) neither of which was apparent early when the procedure was potentially reversible by clip removal. Because of this, as well as theoretical potential for reinnervation with clipping, has kept us from adopting the clip technique. Irrespective of the chosen method of sympathetic chain disruption, the success rates as well as the incidence of postoperative compensatory sweating are quite similar (Table 4). In the majority of patients in our study the compensatory sweating was only a minor inconvenience compared with their preoperative symptoms and our overall satisfaction rate for the procedure at 1-year follow-up was 94%. When compensatory hyperhidrosis is moderate or severe, management is difficult and generally unsatisfactory. We use systemic or topical anticholinergics with variable success. We have referred 1 patient for sural nerve reversal with no benefit. Ninety-nine percent (177/180) of our procedures were performed as an outpatient procedure, with only 3 patients requiring an overnight hospital stay. We were able to demonstrate a high success rates for palmar, axillary, and face/scalp hyperhidrosis. Plantar hyperhidrosis responded with improvement in 58% of patients. In contrast to palmar, axillary, and facial/scalp hyperhidrosis where the improvement is usually complete relief, improvement in plantar symptoms is usually limited to moderate improvement. A valid explanation for this high response rate of plantar symptoms with sympathectomy performed at these levels is not forthcoming. However, improvement in the degree of severity of plantar has consistently been seen in over half of our patients, but there has been no predictability as to which patients will benefit. On the basis of our experience we conclude that thoracoscopic sympathectomy is a safe and effective outpatient method for successfully managing hyperhidrosis. References 1. Lin C-C. Extended thoracoscopic T2 sympathectomy in treatment of hyperhidrosis. Experience with 130 consecutive cases. J Laproendoscopic Surg 1992;2:1. 2. Drott C, Claes G. Hyperhidrosis treated by thoracoscopic sympathectomy. Cardiovasc Surg 1996;XX:788 90. 3. Adur R, Kurchin A, Zweis A, Mozes M. Palmar hyperhidrosis and its surgical treatment: A report of 100 cases. Ann Surg 1977;186:34 71. 4. Hashmonai M, Kopelnam D, Klein O, Schein M. Upper thoracic sympathectomy for primary palmar hyperhidrosis: Long-term follow-up. Br J Surg 1992;79:268 71. 5. Doo Y, Yong H. Needle thoracic sympathectomy for essential hyperhidrosis: Intermediate-term follow-up. Ann Thorac Surg 2000;69:251 3. 6. Kux M. Thoracic endoscopic sympathicotomy in palmar and axillary hyperhidrosis. Arch Surg 1978;113:264 6. 7. Zacherl J, Huber E, Imhof M, Plas E, Herbst F, Fugger R. Long term results of 630 thoracoscopic sympathicotomies for primary hyperhidrosis: The Vienna experience. Eur J Surg 1998;580(Suppl):43 6. 8. Zacherl J, Imhof M, Huber ER, et al. Video assistance reduces complication rate of thoracoscopic sympathectomy for hyperhidrosis. Ann Thorac Surg 1999;68:1177 81. 9. Gossot D, Kabiri H, Caliandro R, Debrosse D, Girard P, Grunenwald D. Early complications of thoracic endoscopic sympathectomy: a prospective study of 940 procedures. Ann Thorac Surg 2001;71:1116 9. 10. Gossot D, Galetta D, Pascal A, et al. Long-term results of endoscopic thoracic sympathectomy for upper limb hyperhidrosis. Ann Thorac Surg 2003;75:1075 9. 11. Yim APC, Liu HP, Lee TW, Wan S, Arifi AA. Needlescopic video-assisted thoracic surgery for palmar hyperhidrosis. Eur J Cardiothorac Surg 2000;17:697 701. 12. Lin T-S, Fang H-Y. Transthoracic endoscopic sympathectomy in the treatment of palmar hyperhidrosis with emphasis on perioperative management. Surg Neurol 1999;52: 453 7. 13. White JC, Smithwick RH, Allen AW, et al. A new muscle splitting incision for resection of the upper thoracic sympathetic ganglia. Surg Gynecol Obstet 1933;56:651 7. 14. Keavery T, Fitzgerald P, Donnelly C, Sharik A. Surgical management of hyperhidrosis. Br J Surg 1977;64:570 1. 15. Golueke P, Garrett W, Thompson J, et al. Dorsal sympethectomy for hyperhidrosis: The posterior paravertebral approach. Surgery 1988;103(5):568 72. 16. Cloward R. Hyperhidrosis. J Neurosurg 1969;30:545 51. 17. Palumbo L. Anterior transthoracic approach for upper thoracic sympathectomy. Arch Surg 1982;72:659 66. 18. Atkins HJB. Sympathectomy by the axillary approach. Lancet 1954;1:538 9. 19. Cambell W, Cooper M, Spousel W, et al. Transaxillary sympathectomy: Is a one stage bilateral approach safe? Br J Surg 1982;69(Suppl):529 31. 20. Goh PM, Cheah WK, DeCosta M, et al. Needlescopic thoracic sympathectomy. Treatment for palmar hyperhidrosis. Ann Thorac Surg 2000;70:240 2. 21. Kao MC, Lin JY, Chen YL, et al. Minimally invasive surgery. Video endoscopic thoracic sympathectomy for palmar hyperhidrosis. Ann Acad Med Singapore 1996;25:673 8. 22. Shachor D, Jederkin R, Olsfanger D, et al. Endoscopic transthoracic sympathectomy in the treatment of primary hyperhidrosis. Arch Surg 1994;129:241 4. 23. Shelley WB, Florence R. Compensatory hyperhidrosis after sympathectomy. N Engl J Med 1960;263:1056 8.

414 DOOLABH ET AL Ann Thorac Surg SYMPATHECTOMY FOR HYPERHIDROSIS 2004;77:410 4 24. Fox AD, Hands L, Collin J. The results of thoracoscopic sympathetic trunk transection for palmar hyperhidrosis and sympathetic ganglionectomy for axillary hyperhidrosis. Eur J Endovasc Surg 1999;17:343 6. 25. Hsia JY, Chen CY, Hsu CP, Shai SE, Yang SS. Outpatient thoracoscopic limited sympathectomy for hyperhidrosis palmaris. Ann Thorac Surg 1999;67:258 9. 26. Lin C-L, Yen L-P, Howag S-L. The long term result of upper dorsal sympathectomy for palmar hyperhidrosis. Jpn J Surg 1999;29:209 13. 27. Reisfeld R, Nguyen R, Pnini A. Endoscopic thoracic sympathectomy for hyperhidrosis, experience with both cauterization and clamping methods. Surgical Laparoscopy 2002;12: 255 67. DISCUSSION DR CARLOS SALDARRIAGA (Medellin, Colombia): Congratulations. It is a nice presentation. I am concerned about this surgery because there are a lot of articles that have reported that only T 2 resection is necessary for palmar hyperhidrosis. You told us about T 3 resection. And my other concern about this is that it is a very painful surgery. Maybe you can do it with two or three incisions, but is very painful. In our country, usually our patients stay one night because of the pain. Thank you very much. DR DOOLABH: Thank you for your questions and comments. Regarding the level of resection, our technique has evolved during our operative period to the point where we now perform at 3 resection for palmar hyperhidrosis. In our experience, we believe by limiting our excision to the T 3 ganglia, our dissection is further away from the stellate ganglion, which may reduce our amount of postoperative compensatory hyperhidrosis and Horner s syndrome. Despite resecting only T 3 for this disease process, our results show a 100% complete resolution of palmar symptoms. To answer your second question regarding the number of incisions, we believe by using three 3-mm ports, this allows us to perform our operation in an expedient fashion, it allows us to utilize the aid of an assistant, and we believe this shortens our operative time, leading to less postoperative discomfort. Our average operative time is 29.3 minutes for a bilateral sympathectomy from skin incision to completion of the procedure. The majority of our patients are operated on Friday, as an outpatient, and most report returning to work the following Monday. DR ERIC VALLIERES (Seattle, WA): Excellent results, beautiful presentation. You did not mention anything about the nerve of Kuntz. In the literature, there is a lot of emphasis on the need to divide this nerve to minimize the risks of failures. Would you comment, please. DR DOOLABH: We don t make any attempts to resect the nerve of Kuntz. The nerve of Kuntz is reported in the literature to be present in about 10% of the population and represents an aberrant connection between the T 3 ganglia and the brachial plexus, in effect, bypassing the circuit of the sympathetic chain. We believe the increased amount of dissection needed to ablate the nerve of Kuntz can contribute to worsening postoperative pain and increase the surgical morbidity of this procedure. We believe our results of recurrence and compensatory symptoms are comparable to that of other published series. (Slide) This is a slide with various other published series, and you can see, despite not resecting the nerve of Kuntz, our response rates are fairly similar. And on the next slide our compensatory rates, despite the various methods of controlling this disease process, are as well similar to other published series. DR JOSE RIBAS M. CAMPOS (São Paulo, Brazil): How do you manage your compensatory hyperhidrosis when this occurs? Do you have any problem with the use of CO 2 during the anesthetic procedure? We know about some records in the literature showing that problems can occur. And finally, on the right side, sometimes you can find big intercostal veins, and how do you manage that? When this happens, you just choose sympathictomy or do you perform the sympathectomy? DR DOOLABH: Regarding severe compensatory hyperhidrosis, we believe the best treatment for severe compensatory hyperhidrosis is, naturally, avoidance. With that said, we minimize our amount of dissection and extent of resection in order to decrease the incidence of this postoperative complication. We have had 2 patients report to us debilitating symptoms and request reversal of this procedure, 1 patient has undergone reversal, and the second patient is waiting for the results of the first. With regard to the use of CO 2 insufflation, we believe this again improves our visualization and the case of the operation. Having said that, we do monitor our patients with an arterial line. Should they develop hemodynamic compromise from tension pneumothorax-related symptoms, we should be able to pick that up in a fairly expeditious fashion. Regarding aberrant venous anatomy on the right side precluding this operation, there have been reports of failure of this operation given the presence of an azygos lobe or abnormal venous connections. We quite honestly, fortunately I think, have not run into this problem but would certainly need to modify our approach if this problem arose. Again, this is a benign disease process, so invoking a surgical operation that may cause significant morbidity is not necessarily in the patients best interest.