James S. Allan and Maria Lucia L. Madariaga
Introduction
Hyperhidrosis is defined as the secretion of perspiration in amounts greater than physiologically necessary for thermoregulation. When generalized, hyperhidrosis often indicates the presence of a systemic disease, such as a febrile illness, an endocrinopathy, or a paraneoplastic syndrome. However, in many patients, hyperhidrosis is confined to focal regions and is a constitutive characteristic of the patient, as opposed to a manifestation of disease. This subset of hyperhidrosis is termed “primary focal hyperhidrosis,” and may, in some cases, benefit from a thoracic sympathectomy.
Primary focal hyperhidrosis affects about 1% to 3% of the general population and often leads to severe functional and psychosocial impairment. Its presence is often observed in early childhood and typically becomes worse as a patient enters adulthood. While not well studied, it seems that such hyperhidrosis begins to abate in the fourth and fifth decades of life. Primary focal hyperhidrosis may affect the axillae (51%), hands (25%), feet (29%), and craniofacial region (20%). Although constitutive in nature, many patients report that their hyperhidrosis is exacerbated by heat or anxiety.
In 2004, the Multi-specialty Working Group on the Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis delineated diagnostic criteria for this disorder:
1. focal, visible, excessive sweating for at least 6 months; and at least two of the following:
2. bilateral and symmetric,
3. impairs daily activities,
4. at least one episode per week,
5. onset before age 25,
6. family history of idiopathic hyperhidrosis (a positive family history occurs in 25% to 50% of all cases),
7. focal sweating stops during sleep.
After systemic illness is ruled out as the cause of hyperhidrosis (which can usually be done on the basis of the medical history alone), no further diagnostic testing is needed. Quantification of sweat production can be performed by galvimetric testing, the Minor starch-iodine test, or the ninhydrin test; however, these data are more useful in the research setting.
Once the diagnosis of primary focal hyperhidrosis is made, the choice of therapy will be based primarily upon the location and the severity of the condition. In general, thoracic sympathectomy (T2-T3) is most efficacious and satisfactory in patients with severe palmar hyperhidrosis that is functionally impairing and refractory to medical therapy (>95% efficacy). It is partially effective in managing hyperhidrosis of the axillae (∼70% partial efficacy).
The effect of thoracic sympathectomy on pedal hyperhidrosis is much more variable, and we do not recommend it to patients who present with pedal hyperhidrosis as their principal complaint.
The reliable surgical treatment of craniofacial hyperhidrosis requires a high sympathectomy, usually requiring ablation of T1 and possibly the lower portion of the stellate ganglion. Because this operation carries a high risk of inducing the Horner syndrome, we do not feel that the benefits of high sympathectomies outweigh the risk.
INDICATIONS/CONTRAINDICATIONS
Assessment of hyperhidrosis severity is important for effective management. The Hyperhidrosis Disease Severity Scale (HDSS, Table 25.1) categorizes disease into “mild” (sweat that is not noticeable and does not interfere with daily activities), “moderate” (sweat is tolerable and sometimes interferes with daily activities), and “severe” (sweat is intolerable and interferes with daily activities). Patients who fall into the “severe” category often fail medical management.
While patients with severe palmar hyperhidrosis are likely to fail medical management, we feel that all patients should undergo a trail of medical therapy tailored to their specific symptoms. First-line treatment generally consists of topical therapy using antiperspirants and/or anticholinergic preparations. The most common, effective topical antiperspirants contain aluminum salts. We usually recommend that a 20% “prescription strength” aluminum salt antiperspirant be applied daily at bedtime to the affected areas. For many patients, a residual benefit lasts throughout the next day. Typical side effects include irritation or maceration of the skin, which is usually dose dependent. We also frequently recommend a compounded preparation of topical glycopyrrolate (2% to 4% w/w), as a cream, lotion, or alcoholic spray. This is typically applied up to three times per day and can be used in conjunction with an antiperspirant. Occasional systemic anticholinergic side effects are seen when large areas are treated aggressively.
As a next line of medical therapy, we typically prescribe an oral anticholinergic agent, such as oxybutynin, which is available in a long-acting formulation suitable for daily use. This class of medication is recommended with all of the caveats and precautions associated with any systemic anticholinergic therapy. Particular care is needed to educate patients about its potential effect of over-inhibiting perspiration, putting the patient at risk for heat stroke. It is best used in combination with topical therapies to maximize effect and minimize the dose-dependent side effects associated with any one particular drug.
TABLE 25.1 Hyperhidrosis Disease Severity Scale (HDSS)
For small areas of focal problematic hyperhidrosis, treatment with botulinum toxin injections is also an option. The drawback to this treatment modality is the need for repeated, often expensive, treatments. It is not practical for use on large areas.
Finally, for axillary hyperhidrosis only, the proprietary miraDry system is also of potential benefit. This treatment modality relies on the use of externally applied microwave energy to ablate the eccrine glands in the axillae. It is not currently approved for use outside the axillae.
We have found other treatments such as clonidine, beta-blockers, calcium channel blockers, benzodiazepines, and iontophoresis to be largely ineffective for most patients.
For patients who fail medical therapy, and who are principally bothered by palmar hyperhidrosis, we will offer a video-assisted thoracoscopic surgery (VATS) sympathectomy, ablating the T2-T3 ganglia. We will also offer this operation to patients with refractory axillary hyperhidrosis, with the understanding that the efficacy of this procedure is somewhat less in this subset of patients. It is imperative that all patients understand that some unpredictable degree of compensatory hyperhidrosis (usually below the T4 dermatomal level) is an expected result of this operation. It is incumbent upon the patient to make the final decision to accept this trade-off. In our experience, a small percentage of patients (<5%) regret having surgery due to excess compensatory hyperhidrosis, despite our best efforts to select and inform patients properly.
PREOPERATIVE PLANNING
There is much controversy over the appropriate level(s) and length of sympathectomy. As stated above, sympathectomies higher than the T2 level are often needed for reliable relief of craniofacial hyperhidrosis, and such sympathectomies carry a very high risk of inducing Horner syndrome. Palmer hyperhidrosis appears to be well controlled with ablations involving T2 and/or T3. Control of axillary hyperhidrosis typically requires a T3-T4 sympathectomy. There is also some evidence to suggest that shorter sympathectomies minimize compensatory hyperhidrosis, usually with some detriment to the primary efficacy of the operation.
In 2011, the International Society on Sympathetic Surgery (ISSS) and The Society of Thoracic Surgeons (STS) General Thoracic Task Force on Hyperhidrosis provided a consensus statement about the surgical treatment of hyperhidrosis. Among their recommendations was the use of a rib-oriented nomenclature, with “R” referring to rib, followed by the rib number and location of nerve division. In practice, the rib level is easier for the surgeon to identify than the sympathetic chain or ganglia, which does not, in reality, have the obvious stylized appearance presented in most anatomy texts.
Using this convention, our practice has focused on reliably treating patients whose primary complaint is palmar hyperhidrosis by means of a sympathectomy beginning on the middle of the second rib, and extending down to the top of the fourth rib, which corresponds roughly to a T2-T3 sympathectomy, allowing for individual anatomic variation. We have found that this approach produces nearly 100% complete and permanent control of palmar sweating, with no occurrences of Horner syndrome, and little (<5%) dissatisfaction due to excessive compensatory hyperhidrosis.
SURGERY
Historically, upper thoracic sympathectomy was performed in an open fashion through posterior, supraclavicular, anterior thoracic, or transaxillary approaches. However, adequate exposure is often difficult via open approaches, and such cases were often accompanied by debilitating muscular pain/dysfunction, scarring, and increased risk of Horner syndrome particularly with the supraclavicular approach.
The advent of videothoracoscopy greatly facilitated the performance of a thoracic sympathectomy, by providing superior visualization and smaller incisions. Today, a bilateral VATS sympathectomy is typically a well-tolerated outpatient procedure that can be accomplished in under an hour.
Figure 25.1 Left axillary exposure with markings for both 5-mm port sites.
Positioning
After intubation with a left-sided double-lumen endotracheal tube, the patient is initially placed onto his/her left side in anticipation of a right-sided procedure. The right arm is abducted and supported to expose the right axilla (Fig. 25.1). The table is placed in steep reverse Trendelenburg and rotated away from the operative side. This allows the isolated lung to lie inferiorly and anteriorly, facilitating exposure to the sympathetic ganglion chain running vertically across the heads of each rib. It is most convenient for both the operating surgeon and assistant to stand at the left side of the table for the right-sided procedure. At the conclusion of the right-sided procedure, it is our preference to reposition the patient onto the opposite side, reprepping and draping, for the left-sided sympathectomy.
Other surgeons have had success positioning the patient supine with arms extended over the head, facilitating exposure by rolling the table hard to one side and then the other. Although our positioning routine is a bit more time-consuming, we feel that the exposure is superior and have never needed to insufflate the chest with CO2. There is also less chance of inducing an ulnar neuropathy, which can be problematic when arms are positioned overhead.
Technique
After prepping and draping, two ports are placed to accommodate 5-mm instruments in the inferior axilla. One is placed over a convenient rib just posteriorly to the pectoral muscle. The other is placed just anterior to the latissimus dorsi muscle (Fig. 25.1). A 5-mm 0-degree straight thoracoscope is inserted through the anterior port, and a long, protected tip cautery is inserted through the posterior port. The thoracoscopic view and a corresponding anatomic diagram are presented for both the right and left sides (Figs. 25.2A–C and 25.3A–C).
Using the cautery, the sympathetic ganglion chain is ablated from the middle of the second rib down to the top of the fourth rib (Fig. 25.4). Care should be taken not to linger with the cautery when ablating the chain over the second rib, to avoid any risk of transmitting cautery energy cephalad toward the region of the stellate ganglion. It is usual for some of the ganglion chain to be obscured by crossing veins. Because unipolar cautery has a zone of effect that extends radially from the instrument tip, we have not found it necessary to dissect out or otherwise manipulate these crossing veins. They can simply be skipped over, resuming the ablation immediately below the vein.
Figure 25.2 A: Thoracoscopic view of right superior-posterior mediastinum. The sympathetic chain runs over the anterior surface of the posterior rib heads. The first rib is not visualized but can be palpated. B: Schematic diagram of right superior-posterior mediastinum. The first rib is outlined. Each sympathetic ganglion and its rami communicantes are seen just below the respective rib level. C: Thoracoscopic view of right thoracic sympathectomy in progress. a, artery; n, nerve; R1, first rib; R2, second rib; R3, third rib; SVC, superior vena cava; symp, sympathetic.
In addition to the direct ablation of the sympathetic chain, it is important to extend a lateral cautery line along the body of the second rib for about 5 cm to divide any accessory sympathetic fibers that might not run with the main body of the sympathetic chain. These accessory sympathetic fibers, which are not always visualized, carry the eponym “accessory nerves of Kuntz” after the neuroanatomist who described them in 1917. The location of the lateral cautery line is shown in Figure 25.4 and can be continuous with the main sympathectomy ablation on the second rib.
After the sympathectomy is complete, the posterior port site is closed, and a temporary pleural drain is placed through the anterior port site. With the drain on suction, the right lung is reinflated, and the patient is repositioned for the left-sided sympathectomy. An identical procedure is performed on the left. The patient is then repositioned supine. Once both lungs are reinflated, and no air is observed to be leaking through either of the pleural drains, the drains are removed, and the anterior port sites are now closed. The patient is recovered from anesthesia.
It should be noted that some surgeons dissect out the sympathetic chain, as a surgical specimen. We have found this not to be necessary and feel that it puts the patient at greater risk of bleeding and conversion to open surgery. Other surgeons prefer to clip (crush) the sympathetic chain at one or more levels. This is often done in hope of the potential benefit of reversibility, should intolerable postoperative compensatory hyperhidrosis occur. However, in practice, clip removal at a second operation is usually not effective in reversing the operation; and when it is effective, the original condition typically returns. We prefer to inform and select patients carefully, so that even if significant hyperhidrosis occurs, the trade-off will be acceptable to the patient.
Figure 25.3 A: Thoracoscopic view of left superior-posterior mediastinum. The sympathetic chain runs over the anterior surface of the posterior rib heads. The first rib is not visualized but can be palpated. B: Schematic diagram of left superior-posterior mediastinum. The first rib is outlined. Each sympathetic ganglion and its rami communicantes are seen just below the respective rib level. C: Thoracoscopic view of left thoracic sympathectomy in progress. a, artery; R1, first rib; R2, second rib; R3, third rib.
Figure 25.4 Pink-shaded area from middle of rib 2 to top of rib 4 shows region of sympathetic chain to cautery ablate. Dashed line depicts cautery line on the second rib to divide accessory sympathetic fibers.
POSTOPERATIVE MANAGEMENT
Once a postoperative chest radiograph and the patient’s clinical condition are satisfactory, the patient can be discharged home with oral pain medication. Patients should be instructed to expect some pain at the incision sites, as well some pleuritic pain in the chest and back. Patients are seen in the office 1 to 2 weeks after surgery for a postoperative evaluation with a chest radiograph.
COMPLICATIONS
Intraoperative complications include all of those typical for any VATS procedure, including bleeding, unintended injury to an adjacent structure, and the need to convert to open surgery to remediate a problem.
Postoperative complications include pneumothorax (requiring a drain in 0.3% to 6% of cases), subcutaneous emphysema (30%), pleural effusion, hemothorax (<1%), chylothorax (rare), brachial plexus injury (rare), wound infection, and Horner syndrome (0% to 5%, usually caused by damage to T1 when the second rib is improperly localized or one is operating for craniofacial hyperhidrosis). In addition, some patients may experience gustatory sweating, defined as facial sweating when eating certain foods (usually spicy or acidic). The rates reported in the literature range from 0% to 38%.
Although not truly a complication, some degree of compensatory hyperhidrosis is an undesired result of most thoracic sympathectomies. It usually involves the trunk, groin, and/or lower extremities. It is to a great extent idiosyncratic although there is some evidence that higher and longer sympathectomies produce more compensatory symptoms. The rates of severe compensatory hyperhidrosis are quite variable in the literature, due to the different sympathectomy techniques that are in common use, and because “degree of severity” is inherently a subjective complaint. Patients with excessive compensatory hyperhidrosis can be treated with the medical modalities discussed above.
RESULTS
The patient’s overall satisfaction following surgery is the most important determinant of surgical success. Questionnaires can be given to patients to determine the symptom baseline and whether surgery was effective. For example, using the HDSS, a one-point improvement in HDSS score is associated with 50% reduction in sweat production; a two-point improvement in HDSS score is associated with 80% reduction in sweat production. Ultimately, satisfaction is mainly determined by the success of primary symptom control.
For facial blushing and facial hyperhidrosis, patient satisfaction rates were 85% to 94%, failure rates were 6% to 15%, and the incidence of compensatory hyperhidrosis rates was 67% to 95%.
For palmar hyperhidrosis, among the largest series (78 to 1,360 patients), patient satisfaction rates were 92% to 97%, failure rates were 1% to 25%, and the incidence of compensatory hyperhidrosis rates was 67% to 92%. Two other large series of patients where T4 and T5 block was performed showed that patient satisfaction rates were 99%, failure rates were 0% to 8%, and the incidence of compensatory hyperhidrosis rates was 0% to 17%.
For axillary hyperhidrosis, patient satisfaction rates were 60% to 90%, failure rates were 0.9% to 21%, and the incidence of compensatory hyperhidrosis rates was 17% to 82%.
For plantar hyperhidrosis, about 50% of patients see improvement in symptoms initially; this decreases to 25% over time.
CONCLUSIONS
Severe focal hyperhidrosis affects a small percentage of the population but can be functionally impairing and psychosocially undesirable. For patients who present with focal hyperhidrosis, a trail of medical therapy is appropriate, recognizing that patients with severe symptoms are likely to be refractory to medical treatment. For patients with palmar hyperhidrosis (and to a lesser extent, axillary hyperhidrosis), a T2-T3 sympathectomy, as described above, provides near universal control of symptoms, with a low rate of severe compensatory hyperhidrosis. We are reluctant to operate on patients whose primary complaint is craniofacial hyperhidrosis, due to the need for a higher sympathectomy and the attendant risks with that procedure. We are also reluctant to perform thoracic sympathectomy for isolated pedal hyperhidrosis, as its efficacy is poor and unreliable.
The operative procedure that we have presented above is one that is designed to maximize surgical exposure, minimize surgical manipulation, and reduce the likelihood of surgical complications. For patients with severe medically refractory palmar hyperhidrosis, we have recorded an overall satisfaction rate exceeding 90% on a large number of cases without any serious complications. Further investigation and experience is still needed to determine the optimal sympathectomy level for specific patient populations.
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