Thoracoscopic Sympathectomy: A Standardized Approach to Therapy for Hyperhidrosis

doi:10.1016/j.athoracsur.2007.12.005

The Annals of Thoracic Surgery

Volume 85, Issue 2, February 2008, Pages S764-S767

Presented at the Minimally Invasive Thoracic Surgery Summit, New York, NY, June 8–9, 2007.

https://doi.org/10.1016/j.athoracsur.2007.12.005 Get rights and content

Thoracoscopic sympathectomy has been used for the treatment of sympathetic dysfunction since it was first described in the 1940s. With the advent of video-assisted thoracic surgery, the procedure has become more widely applied. Video-assisted thoracic surgery allows excellent visual acuity as well as the possibility of doing the procedure more quickly and with fewer complications. This article presents a review of existing approaches and techniques as well as the author’s summary and preferences. The review of the articles on thoracoscopic sympathectomy only included those from the English literature.

Section snippets

Indications

Thoracic sympathectomy has been used for the treatment of a variety of sympathetic disorders since it was first described in the 1940s. These include but are not limited to hyperhidrosis, reflex sympathetic dystrophy, upper extremity ischemia, Raynaud disease, and splanchnicectomy for pancreatic pain. The most common indication, and the indication in which the results are most satisfactory, is hyperhidrosis. Most of this paper will therefore refer primarily to hyperhidrosis patients.

It is

Definition of Terms

Many different terms have been used to describe the actual procedure that is performed in different reports of sympathectomy. Unfortunately, the terminology is generally inconsistent and often leads to confusion. The following glossary has been proposed and corresponds to the most common surgical approaches to thoracic sympathectomy:

•
Thoracoscopic—done with any means of thoracoscopy, including video- and standard eyepiece–assisted procedures.
•
Video-assisted thoracic surgery (VATS)—refers only to

Technique

Many different options are used for the level of transection, technique of division, ablation, and anesthetic technique. The next section describes the most common options described in the literature and offers my preferences, when appropriate.

Results

We previously reported our results in 397 consecutive thoracoscopic sympathectomy procedures, which were synchronous bilateral in 194 patients, right side alone in 6; left side alone in 1; and staged in 1. There were 97 males (48%) and 105 females (52%). The mean age was 29 years (range, 9 to 65 years). The indications were hyperhidrosis in 175 patients, facial blushing in 21, Raynaud in 3, digital ischemia in 2, and reflex sympathetic dystrophy in 1 patient. Compensatory sweating occurred in

Conclusion

In conclusion, thoracoscopic sympathectomy can be done as an outpatient procedure safely and efficiently. Debate continues about the correct transection levels, but at this time there is a consensus that division or clipping is equal to resection. Although the procedure has several severe side effects, they are rare. The predominant complication remains compensatory sweating, which may occur regardless of the level transected or the indication. Future clinical trials should compare some of the

References (15)

K. Kwong et al.
“Clinical experience in 397 consecutive thoracoscopic sympathectomies”
Ann Thorac Surg
(2005)
J. Milanez de Campos et al.
Quality of life, before and after thoracic sympathectomy: report on 378 operated patients
Ann Thorac Surg
(2003)
T. Lin et al.
Transthoracic endoscopic sympathectomy in the treatment of palmar hyperhidrosis–with emphasis on perioperative management (1,360 case analyses)
Surg Neurol
(1999)
D. Lee et al.
Selective division of T3 rami communicantes (T3 ramicotomy) in the treatment of palmar hyperhidrosis
Ann Thorac Surg
(2004)
D. Gossot et al.
Thoracoscopic sympathectomy for upper limb hyperhidrosis: Looking for the right operation
Ann Thorac Surg
(1997)
D. Kopelman et al.
Upper dorsal thoracoscopic sympathectomy for palmar hyperhidrosis: improved intermediate term results
J Vasc Surg
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M. Noppen et al.
Changes in cardiocirculatory autonomic function after thoracoscopic upper dorsal sympathicolysis for essential hyperhidrosis
J Auton Nerv Sys
(1996)

There are more references available in the full text version of this article.

Cited by (40)

Endoscopic thoracic sympathicotomy for primary palmar hyperhidrosis: A retrospective multicenter study in China
2019, Surgery (United States)
Citation Excerpt :
In 2010, we conducted a national survey and found that the PPH prevalence rate of adolescents was 2.1% in mainland China.5 Some literature reported that endoscopic thoracic sympathicotomy (ETS) is a safe and effective means to treat PPH.6,7 Transfer hyperhidrosis (TH), when body parts (such as trunk or lower limbs) that are normal before surgery may sweat excessively after the operation is, however, the most undesirable side effect of ETS.
This study aimed to evaluate the clinical efficacy and safety of endoscopic thoracic sympathicotomy and to explore strategies to decrease the incidence of transfer hyperhidrosis (TH).
From January 2003 to July 2016, 10,275 patients with primary palmar hyperhidrosis underwent endoscopic thoracic sympathicotomy in 15 different institutions. We carried out a retrospective analysis of these patients who were grouped into group A, those with nonretained R2 (R2, R2–3, or R2–4 ablation), and group B, those with retained R2 (single R3 or R4 ablation).
All procedures were performed successfully. Both hands of all patients became warm and dry immediately after endoscopic thoracic sympathicotomy. Pneumothorax occurred in 146 patients, and 39 patients had intraoperative bleeding. Follow-up was carried out from 6 months to 13 years. A total of 531 patients (5.2%) were lost to follow-up. The effective rate for primary palmar hyperhidrosis was 100%. Palmar hyperhidrosis recurred in 73 patients (0.7%). Transfer hyperhidrosis appeared in 7,678 patients (78.8%). For groups A and B, the incidence of TH was 80.4% and 78.5%, respectively (P > .05), but the incidence of grade III+IV TH in group B (1.6%) was less than that in group A (4.8%; P < .001).
Endoscopic thoracic sympathicotomy is a minimally invasive, safe, and effective therapeutic method for primary palmar hyperhidrosis. Although the overall incidence of TH is high, the incidence of grade III to IV TH can be decreased by reserving R2, lowering the level of thoracic sympathicotomy, and single severing of R3 or R4.
A New Device of Needlescopic Thoracic Sympathectomy Through a Skin Incision
2017, Annals of Thoracic Surgery
Citation Excerpt :
Operation on the sympathetic nerve includes various procedures, including sympathectomy, sympathecotomy, ganglionectomy, ablation, and clipping. Until now, different terms have been used in previous reports on surgical procedures on sympathetic nerves [5]. In conventional needle sympathectomy through a single skin incision, the three procedures—sympathectomy, sympathecotomy, and ablation—were possible.
We describe a new technique of performing sympathectomy with a new device. A single skin incision 3 mm long was made in the armpit. The device enables complete resection of the sympathetic segment through a single skin incision, whereas sympathectomy is limited by the use of the conventional needle technique. Even if sympathetic nerves and blood vessels were overlapping, separation of the two organs was performed safely. This device increases the possibility of planning surgical procedures for patients with difficult anatomies.
Video-Assisted Thoracic Sympathectomy for Hyperhidrosis
2016, Thoracic Surgery Clinics
Citation Excerpt :
Despite the satisfactory results achieved by these authors, and for unknown reasons, the technique did not find international acceptance for more than 30 years.3 By the 1980s, endoscopy was in use by some groups in sympathetic denervation of the upper limbs with vascular indications, but it was only in the 1990s that advances in optical systems and instrumentation for thoracic endoscopy made it possible to adopt the technique to perform thoracic sympathectomy as it is known today.4,5 Low morbidity, good cosmetic results, reduction in the incidence of Horner syndrome, and the shortened time in hospital made video-assisted thoracic sympathectomy (VATS) better accepted by those undergoing treatment for hyperhidrosis.
Pulmonary Surgery
2016, Nunn's Applied Respiratory Physiology
Quality of life before hyperhidrosis treatment as a predictive factor for oxybutynin treatment outcomes in palmar and axillary hyperhidrosis
2014, Annals of Vascular Surgery
Citation Excerpt :
Hyperhidrosis is a disorder that may affect as much as 3% of overall population, causing substantial interference in QOL. This condition commonly manifests during childhood and may persist throughout adult life.20 The growing knowledge of this disorder and new therapeutic options available are encouraging more patients to seek medical assistance.
Studies have suggested that quality of life (QOL) evaluation before video-assisted thoracoscopic sympathectomy for patients with hyperhidrosis may serve as a predictive factor for positive postoperative outcomes. Our study aims to analyze if this tendency is also observed in patients treated with oxybutynin for palmar and axillary hyperhidrosis.
Five hundred sixty-five patients who submitted to a protocol treatment with oxybutynin were retrospectively analyzed between January 2007 and January 2012 and were divided into 2 groups according to QOL assessment before treatment. The groups consisted of 176 patients with “poor” and 389 patients with “very poor” QOL evaluation before oxybutynin treatment. Outcomes involving improvements in QOL and clinical progression of hyperhidrosis were evaluated using a validated clinical questionnaire that was specifically designed to assess satisfaction in patients with excessive sweating.
Improvements in hyperhidrosis after oxybutynin were observed in 65.5% of patients with very poor pretreatment QOL scores and in 75% of patients with poor pretreatment QOL scores, and the only adverse event associated with oxybutynin treatment was dry mouth, which was observed with greater intensity in patients with very poor initial QOL evaluation.
Improvements in hyperhidrosis after oxybutynin treatment were similar in both groups, suggesting that QOL before treatment is not a predictive factor for clinical outcomes, contrasting with surgical results that disclose significantly better results in patients with initially poorer QOL analysis.
Usage of EZ-blocker on bilateral videothoracoscopic sympathectomy
2013, Journal of Cardiothoracic and Vascular Anesthesia

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Supplement: The Minimally Invasive Thoracic Surgery SummitSection III: MediastinumThoracoscopic Sympathectomy: A Standardized Approach to Therapy for Hyperhidrosis

Section snippets

Indications

Definition of Terms

Technique

Results

Conclusion

Ann Thorac Surg

Ann Thorac Surg

Surg Neurol

Ann Thorac Surg

Ann Thorac Surg

J Vasc Surg

J Auton Nerv Sys

Supplement: The Minimally Invasive Thoracic Surgery Summit
Section III: Mediastinum
Thoracoscopic Sympathectomy: A Standardized Approach to Therapy for Hyperhidrosis