Abstract
Objective
Compensatory hyperhidrosis is a common devastating adverse effect following endoscopic thoracic sympathectomy for patients undergoing surgical treatment of primary hyperhidrosis. We sought to determine if there was a correlation in our patient population between the level and extent of sympathetic chain resection and the subsequent development of compensatory hyperhidrosis.
Methods
All patients undergoing endoscopic thoracic sympathectomy in the T2-3, T2-4, T2-5, or T2-6 levels for palmar or axillary hyperhidrosis at the University of Iowa Hospital and Clinics (n=97) between January 2004 and January 2013 were retrospectively reviewed.
Results
Differences in preoperative patient characteristics were not statistically significant between patients receiving either T2-3, T2-4, T2-5, or T2-6 level resections. Of the ninety-seven patients included in this study, twenty-eight patients (29%) experienced transient compensatory hyperhidrosis and four patients (4%) complained of severe compensatory hyperhidrosis and required further treatment. There were no operative mortalities and morbidity was similar amongst the groups.
Conclusions
Most patients had successful outcomes after undergoing extensive resection without change in incidence of compensatory hyperhidrosis. Therefore, we recommend performing a complete and adequate resection for relief of symptoms in patients with primary hyperhidrosis.
Introduction
Primary focal hyperhidrosis affects 1-3% of the population and is characterized by increased perspiration out of proportion to what is physiologically needed for thermoregulation.[1] Primary focal hyperhidrosis is a chronic idiopathic condition defined as focal, visible, and excessive sweating of at least six months duration accompanied by two of the following characteristics: bilateral and symmetric symptoms, onset before age 25, impairment of daily activities, at least one episode per week, focal sweating that ceases during sleep, or a family history of hyperhidrosis.[2] It most commonly affects the palms, axillae, and plantar surfaces.[2] The pathophysiology behind primary hyperhidrosis is not well understood. It has been postulated that an abnormal or exaggerated response to emotional stressors by the hypothalamus or cerebral cortex causes increased autonomic signaling to eccrine sweat glands.[3] While benign in nature, hyperhidrosis can cause soaking of papers, clothes, and shoes, may lead to avoidance of social situations and limitations in professional and physical activities, and result in emotional and psychological distress.
When topical and medical treatments fail to resolve excessive sweating, Endoscopic Thoracic Sympathectomy (ETS) is an effective surgical treatment for severe primary palmar hyperhidrosis with high patient satisfaction rates. The most common devastating adverse effect following ETS is compensatory hyperhidrosis (CH), defined as subjectively increased sweating at parts of the body not anatomically affected by the sympathectomy. CH is thought to be a thermoregulatory response by which the body compensates for the lack of perspiration at surgically dennervated regions by increasing perspiration in unaffected areas including the trunk, lumbar, groin, thigh, and popliteal regions.[4] Widespread hyperhidrosis prior to surgery, older age, higher BMI, high ambient temperature, and family history of primary hyperhidrosis are risk factors for development of CH.[5, 6] Rates of CH cited in the literature range from 3% to 98% depending on how CH is assessed.[5] In attempts to decrease the incidence of CH, many have suggested limiting the magnitude of resection of the sympathetic chain will decrease the incidence of postoperative CH. However, controversy still exists as to the appropriate level and number of ganglia to be removed for the best outcome. Our aim was to review the series of ETS performed at our institution to determine if the level of resection influences the long-term results or overall outcome of the procedure.
Methods
Between January 2004 and January 2013, all patients undergoing endoscopic thoracic sympathectomy (ETS) in the T2-3, T2-4, T2-5, and T2-6 levels for palmar or axillary hyperhidrosis at the University of Iowa Hospital and Clinics (n=97) were included in a retrospective chart review. A total of seven cases of ETS performed in different levels than the four groups, all of which did not report CH, were omitted from this study due to inadequate sample size, . Data obtained included patient demographics, family history, site of primary hyperhidrosis, previous therapies, surgical details, outcome, and complications. Patient demographics are listed in Table 1. Thirty-nine patients (40%) experienced widespread hyperhidrosis with excessive perspiration at palmar, axillary, and plantar locations. Of the 97 total operations, 96 were bilateral ETS. One patient had a planned staged procedure; he had previously received a right-sided ETS and only the left-sided ETS was performed at our institution. Level of sympathetic ganglia removal is shown in Table 2. A total of seven different surgeons performed the operations.
Table 1.
Preoperative patient characteristics by level of sympathectomy
| Variablea | T2-3 (n=9) |
T2-4 (n=11) |
T2-5 (n=36) |
T2-6 (n=41) |
p value |
|---|---|---|---|---|---|
| Female | 6 (67%) | 5 (45%) | 21 (58%) | 28 (68%) | 0.522 |
| Age | 17 (13-32) | 20 (14-36) | 21 (13-59) | 21 (13-66) | 0.288 |
| BMI | 22 (20-28) | 25 (19-33) | 25 (18-47) | 24 (20-36) | 0.398 |
| Family history | 2 (22%) | 1 (9%) | 4 (11%) | 5 (12%) | 0.888 |
| Primary symptoms | |||||
| Axillary | 6 (67%) | 6 (55%) | 24 (67%) | 29 (71%) | 0.787 |
| Palmar | 8 (89%) | 10 (91%) | 30 (83%) | 37 (90%) | 0.803 |
| Plantar | 7 (78%) | 6 (55%) | 23 (64%) | 25 (61%) | 0.755 |
| Widespread | 5 (56%) | 3 (27%) | 13 (36%) | 18 (44%) | 0.546 |
| Prior treatment | |||||
| Botulinum toxin | 1 (11%) | 8 (73%) | 11 (31%) | 20 (49%) | 0.235 |
| Iontophoresis | 4 (44%) | 2 (18%) | 10 (28%) | 11 (27%) | 0.622 |
Continuous data are shown as median (range) and categoric data are shown as n (%) BMI = body mass index
Table 2.
Operative outcomes by level of sympathectomy
| Variablea | T2-3 (n=9) |
T2-4 (n=11) |
T2-5 (n=36) |
T2-6 (n=41) |
|---|---|---|---|---|
| Severe CH | 0 (0%) | 0 (0%) | 3 (8%) | 1 (2%) |
| Transient CH | 3 (33%) | 4 (36%) | 12 (33%) | 9 (22%) |
| Location of transient CH | ||||
| Chest | 0 (0%) | 1 (9%) | 4 (11%) | 1 (2%) |
| Abdomen | 3 (33%) | 3 (27%) | 7 (19%) | 7 (17%) |
| Lumbar region | 3 (33%) | 2 (18%) | 10 (27%) | 4 (10%) |
| Buttocks | 0 (0%) | 0 (0%) | 2 (6%) | 0 (0%) |
| Thighs | 0 (0%) | 1 (9%) | 5 (14%) | 2 (5%) |
| Popliteal | 1 (11%) | 0 (0%) | 1 (3%) | 1 (2%) |
Continuous data are shown as median (range) and categoric data are shown as n (%) CH = compensatory hyperhidrosis
Operative technique
Endoscopic thoracic sympathectomy is performed as a bilateral procedure with the patient in the lateral decubitus position utilizing single lung ventilation with a double lumen tube. The arm is mildly hyperextended for exposure to the axillae. Three 5 mm thoracoscopic ports are used and placed with two in the axillae at the level of the hairline for the highest port and the other in the 5th intercostal space in the mid axillary line. After the lung has been deflated, the lowest port is inserted with a stab incision without the use of electro cautery or spreading to prevent skin damage. The other two ports are placed in the axillae with the highest port placed first so as not to obstruct the view for the placement of the third port one rib space below the highest port. The lung is manipulated and compressed away from the spine to provide visualization of the sympathetic chain. The first rib is identified, and the second through the 6 ribs are marked with electro cautery 3-5 cm away from the chain laterally to assure the level of resection stays below the first rib.
Next, the lowest level is identified, and the pleura immediately lateral to the chain is opened from the lowest point to the highest point. The lowest point of the chain is then isolated and grasped with the 5 mm grasper proximally and divided with electro cautery distally. With traction in a cranial and anterior direction, the chain is gently removed using electro cautery to separate the chain from the surrounding tissues as well as the intercostal vessels and attachments.
Each ganglion is dissected using cautery until the second ganglion is reached, and the chain is then divided just below the second rib after removing the ganglion sharply with scissors. The area is monitored for hemostasis, and the pleura that laterally overlies the rib is superficially incised for a distance of 4-5 cm from the chain laterally with electro cautery to divide any accessory nerves which might remain. A 14F rubber catheter with multiple holes is inserted into the chest, and the lung is re-inflated with suction applied to the catheter to allow full re- expansion of the lung. The tube is then withdrawn on suction and with positive pressure of 30cm of water applied to the lungs. The wounds are then closed with tissue adhesives. A similar procedure is then carried out on the other side. No chest tube or drain is used. The patient is discharged after a chest x-ray to document pulmonary re-expansion.
Statistical Analysis
Univariate comparisons of preoperative variables were performed between ETS levels T2-3, T2- 4, T2-5, and T2-6. Categorical variables were tested using the chi-square test and continuous variables were assessed by the ANOVA test for association. Univariate comparison of the postoperative variables including the incidence of CH was not performed due to the low sample size in the T2-3 and T2-4 resection groups. All analyses were performed using SPSS Statistics Version 21 (IBM Corp, Armonk, NY).
Results
Ninety-seven patients receiving ETS for palmar or axillary hyperhidrosis were included in this study. The sample consisted of 60 women and 37 men, with an average age of 24 years (range 13-66 years). Patients suffered from hyperhidrosis at one or more sites including 85 with palmar (88%), 65 with axillary (67%), and 61 with plantar (63%) regions. Twelve patients (12%) reported a family history of hyperhidrosis. All patients were treated prior to surgery with medical management. This included oral glycopyrrolate (Robinul), topical aluminum chloride hexahydrate 20% (Drysol), iontophoresis with Drionic (General Medical Company, Pasadena, CA, USA), injections of Botulinum toxin A, and oral clonidine. Medical interventions failed in all patients included in this study. The differences in measured preoperative variables between the four groups were not statistically significant.
Sympathetic levels T2-6 were removed in 41 patients (42%), followed by removal of T2-5 in 36 patients (37%), T2-4 in 11 patients (11%), and T2-3 in 9 patients (9%). There were no mortalities. Length of stay (LOS) was less than 23 hours for all patients. All patients experienced resolution of palmar hyperhidrosis. Additionally, of the 61 patients with plantar hyperhidrosis, 7 experienced complete resolution of symptoms, and 4 reported decreased symptoms. Morbidities included four pneumothoraces, one episode of subcutaneous emphysema, in addition to CH. Pneumothoraces and subcutaneous emphysema resolved spontaneously without chest tube placement. There were no reports of Horner syndrome, excessive bleeding, or infection. The majority of patients were satisfied with the results of the procedure.
CH was characterized as either transient or severe. Transient CH was defined as a minor increase in sweating that is present for less than 90 days at any level, while severe CH was defined as persistent sweating for 90 days or greater requiring further treatment. Twenty-eight patients (29%) experienced transient CH. The breakdown of patients who experienced CH as well as the location of transient CH based on level of sympathectomy is shown in Table 2. Four patients (4%) complained of severe CH and required further treatment. One patient with T2-T6 ETS had CH affecting the abdomen, lower back, and thighs with extremely dry hands, axillae, and upper torso; documentation of the patient’s further medical treatment was unavailable. Three patients with T2-T5 ETS experienced severe CH. The first had severe CH from the nipple line to the feet that was managed post-operatively with Robinul, Drysol, and multiple Botulinum toxin A injections. The second and third patients with severe CH reported sweating on the trunk, requiring further treatment with Robinul and Drysol.
Discussion
For patients with medically refractory palmar hyperhidrosis, ETS successfully resolves symptoms in almost every patient.[7] The most devastating common complication following ETS is compensatory hyperhidrosis, with an incidence reported at 3% to 98%.[5] Since the goal of ETS is to improve the patient’s quality of life, complications should be minimized or eliminated. For this reason, many have offered recommendations to eliminate CH. However, controversy still exists regarding specific surgical technique, the level of resection, and the number of levels resected to minimize CH while maximizing beneficial outcomes.
In this study, ninety-seven patients received ETS after their hyperhidrosis was deemed refractory to medical management. Most patients at our institution received either a T2-6 or T2-5 resection, which is more extensive than what is performed at many other institutions, which generally resect or ablate one to two levels of the sympathetic chain. In spite of our larger resection, the rate of transient compensatory hyperhidrosis at our institution is 29%, which is similar to that reported in the literature of patient populations receiving resections of only one or two ganglia.[8-10] Similarly, the rate of severe CH at our institution was 4.1%, which is in keeping with the lowest rates reported in literature.[5]
We defined severe CH as persistent excessive perspiration greater than 90 days after surgery that required additional treatment. In our experience, many patients complain of minor increased sweating in the initial weeks and months after surgery. Patients with complaints of CH are given an appointment 1 month after ETS and then asked to follow up at 3 and 6 months post ETS. The majority of patients with CH cancel follow up appointments as their CH resolves spontaneously.
It has been postulated that CH is a thermoregulatory response of remaining sweat glands after denervation of many upper extremity sweat glands by ETS.[4] There have been many suggestions to limit the number of levels affected by ETS as much as possible. It was initially thought that fibers from T2 alone innervate eccrine sweat glands in the upper extremity, and so it was recommended that T2 alone be divided.[8] However, it was then discovered that many patients have postganglionic nerves, called accessory nerves of Kuntz, leaving the sympathetic chain at the T3 or T4 level and entering the brachial plexus to innervate the upper extremity. This led to recommendations to denervate not only T2, but also T2-T3 or even T2-T4.[8]
In a 2009 review of 282 patients treated with ETS, Miller et al. advocate division of the sympathetic chain at the T2 level only. They report a significant decrease in CH in the T2 division group as opposed to the T2-T4 group with multiple divisions of the chain; 13% of the T2 group experienced CH and 34% of the T2-T4 group experienced CH.[6] In contrast, based on results of a 2009 prospective randomized control study of 60 patients receiving ETS by division and thermablation of either the T2 or T3 ganglion, Yazbek et al. recommend division of the T3 ganglion only to reduce CH. By 20 month follow up, all patients in the study reported some degree of CH. Patients in the T2 group had significantly more severe (defined as visible, embarrassing, and requiring a change of clothing) and non-severe CH than those in the T3 group. However, there was no statistically significant difference in patient-reported quality of life at 1, 6, or 20 months.[8]
Others suggest interruption of the sympathetic chain in multiple locations. In 2011, the Society of Thoracic Surgeons (STS) conducted a review of over 400 studies. They concluded that patients with palmar hyperhidrosis should receive a T3 and/or T4 sympathectomy; patients with T3 sympathectomy had increased CH, while patients with T4 sympathectomy had incomplete resolution of palmar sweating. For patients with widespread hyperhidrosis at palmar, axillary, and plantar sites, STS recommends T4 and T5 sympathectomy.[5]
Several studies have shown that division of T2, T3, or T4 or some combination reduces CH. However, many studies suggest that CH occurs to many patients receiving sympathectomy for hyperhidrosis regardless of the level of division. Katara et al. reported 25 patients who had T2 division on one side and T2-3 division on the other side; these patients all experienced resolution of symptoms bilaterally, and 80% developed CH bilaterally, suggesting that the level of chain interruption did not affect development of CH.[10] Similarly, Leseche et al. reviewed 134 patients with multiple different levels of resection from T1-T5 and noted no significant correlation between the extent of resection and the incidence or severity of CH.[11] Chwajol et al. also reviewed patients receiving various levels of resection from T2-T4 and concluded that there was no difference in incidence of CH by level of resection; they only difference they noted was a significant decrease in severe, debilitating CH in the T3 resection group.[12] In a 2008 review of 87 articles, Kopelman et al. looked at the effect of multiple combinations of T1, T2, T3, T4, and T5 sympatectomy by various techniques. They concluded that limiting the level of sympathetic ablation does not decrease the incidence of CH.[13] Thus, in several relatively large studies looking at multiple different chain resection combinations, there was no difference in incidence of CH.
The primary shortcomings of our study were the retrospective nature and the small sample size for the T2-3 and T2-4 groups. Patients in this study were not randomized to resection groups and paired for analysis, which limits direct statistical comparison. Additionally, the disparity in number of patients between the resection groups negatively impacted meaningful statistical analysis. As mentioned above, the extent of ganglion resection in our patients was larger than in many other studies, and yet the incidence of transient and severe compensatory hyperhidrosis were similar to that consistently reported in the literature among those advocating for resection of only one or two ganglia.
Conclusion
The results of this retrospective study indicate that in our patient population there is littledifference in outcome or in incidence of compensatory hyperhidrosis regardless of the level or extent of resection. Importantly, most of our patients underwent extensive resection with a successful outcome without change in incidence of CH, and therefore we do not recommend limiting the resection level in an attempt to limit CH. Since the extent of resection had no effect on the occurrence of compensatory hyperhidrosis and other complications, we recommend performing a complete and adequate resection for relief of symptoms in patients with primary hyperhidrosis.
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