Severe Hyperhidrosis: Clinical Features and Current Thoracoscopic Surgical Management

Background: Severe hyperhidrosis is a debilitating disorder primarily affecting the palmar, plantar, and axillary regions. The purpose of our study was to review patient characteristics, surgical technique, and outcome of patients undergoing outpatient thoracoscopic sympathectomy for severe hyperhidrosis.

Methods: A series of 309 hyperhidrosis patients underwent thoracoscopy for T2-T3 sympathectomy. Of these, 180 underwent prospective evaluation to more precisely identify pre- and postoperative features.

Results: The primary indication for surgery was palmar hyperhidrosis (PH) in 302 of 309 patients (97.7%), although in 7 patients (2.3%) axillary hyperhidrosis (AH) was the primary indication. A family history was elicited in 74 of 132 (56.01%) and a provocative response to hand lotion was present in 101 of 132 (76.5%). Thoracoscopic sympathectomy afforded almost instantaneous cures for PH, with marked improvement in 100% for whom the sympathectomy was done. Of 180 patients prospectively questioned in detail, 173 (96.1%) had some degree of plantar hyperhidrosis. Of these, 148 (84.4%) had some improvement, with 70 (40.5%) achieving complete relief of the plantar hyperhidrosis. In 98 patients who had some complaints of AH, 68 (69.4%) were completely relieved with the AH, while 25 (25.5%) were relieved but not completely cured. In 7 patients, the primary indication for sympathectomy was AH and of these, 3 (42.9%) had complete relief, 2 (28.6%) had partial relief, and 2 (28.6%) had no relief. Of the entire series of 309 patients, 4 (1.3%) developed severe compensatory hyperhidrosis (CH). In 180 prospectively questioned patients, CH was present in 81 (45%).

Conclusion: The most frequent presentation of hyperhidrosis involves the hands and feet. A family history of the disorder is common, and there is usually a provocative effect with hand lotion. Sympathectomy at the level of the T2-T3 ganglia is curative for PH, and in 80% of instances will improve plantar hyperhidrosis when in combination with PH. Sympathectomy for AH is not as effective as for PH. CH is common, occurring in nearly half, but only rarely is extreme and problematic. Bilateral thoracoscopic sympathectomy may be safely done as outpatient procedure for most patients.

(Ann Thorac Surg 2003;76:000-000)
© 2003 by The Society of Thoracic Surgeons

Primary hyperhidrosis is a disorder of excessive perspiration most problematic when it involves the hands, but frequently also involves the feet and axillae and, to a lesser extent, face, trunk, and scalp [1]. The disorder can be severe and debilitating for patients professionally and socially, interfering with school, work, the activities of daily living, and normal interpersonal interactions. For severe hyperhidrosis, conservative measures including topical aluminum chloride, ionotophoresis, oral anticholinergics, and Botulinum Toxin of Type A injection are completely unsatisfactory, and surgery offers the only chance for any effective, long-term cure of the disorder [2]. Upper thoracic sympathectomy leads to complete resolution of upper extremity hyperhidrosis. Thoracoscopic sympathectomy was first reported in 1942 [3], and since then advances in endoscopic video technology have been successfully applied [4]. The purpose of our study was to review the characteristics of our patients undergoing surgery for severe hyperhidrosis, and to evaluate the feasibility and outcome of performing bilateral thoracoscopic sympathectomies at one sitting in the outpatient setting. Outcomes were measured in terms of cure of the primary disorder and incidence of compensatory sweating or other untoward events.

MATERIAL AND METHODS

Patients undergoing thoracoscopic sympathectomy by a single surgeon, primarilly at a single same-day outpatient surgery center from January to December 2002,were reviewed. All had severe hyperhidrosis, usually palmar, and most had been on some form of nonsurgical treatment. Single lumen endotracheal intubation was performed, and the patient positioned supine with both arms outstretched to the sides. Reverse Trendelenberg and rotation of the patient away from the side of the surgery facilitated exposure. A 5 mm trochar and scope were inserted via the fourth or fifth intercostal space, anterior axillary line, immediately superior to the rib to avoid injury to the intercostal neurovascular structures. Carbon dioxide (CO2) insufflation was done to an approximate 12 mm Hg to deflate the lungs under endoscopic guidance. Another 5 mm trochar is passed into the chest at the base of the axillary hairline and a spatula cautery used to cauterize (transect) the sympathetic chain at the evel of the second and third thoracic ganlia overlying their corresponding ribs. The cautery transection is limited to that part of the nerve directly overlying the costal head, avoiding the intercostal space and its neurovascular structures. Futher levels beyond the 2nd and 3rd ganglia are not taken, even if axillary hyperhidrosis is the primary complaint. In cases of poor visibility of the 1st rib due to fat, the rib can usually be palpated with an instrument. If the sympatic ganglia is abutting up against a large vein, as frequently happens for the ganglia in the right hemithorax, a dissector instrument is used to tease away the parietal pleura overlying the ganglia in order to carefully grasp the ganglion directly. In rare cases of poor visualization around the lung apex, insufflation will be increased up to 20 mm Hg for a shor time to compress the apex. Although pressures up to 15mm Hg are usually will tolerated, higher pressures, particularly in the left hemithorax, rapidly lead to tension pneumothorax-related electromechanical dissociation (EMD), which is immediately reversed by release of the intrathoracic carbon dioxice. The phenomenon nearly always occurs on the left. A pulse oximeter, esophageal stethoscope, and continuous eletrocardiographic monitoring have been utilized without the need for an arteral line. If adhesions were encounted, the scope could often be used to bluntly punch a hole through a veil of adhesions to enter a clear space. If the apex remains firmly adherent in the superior sulcus, the scope can sometimes be passed posterior to the lung to reach the upper posterior mediastinum, with or without a counterincision for lung retraction.

COMMENT

The autonomic nervous system is comprised of nerves which supply all glands, blood vessels, and smooth and cardiac muscle tissues. The autonomic system (unlike the somatic equivalent) with neuronal cell bodies of postsynaptic neurons located in ganglia peripheral to the central nervous system (CNS) (Fig 1). The sympathetic nervous system has its preganglionic neuronal cell bodies in the lateral horn of the spinal cord between T1 and L2 to 3. The myelinated preganglionic nerves exit the cord via corresponding spinal roots and communicate with the sympathetic ganglia, where they synapse with postganglionic sympathetic neurons. The thoracic ganglia (except for the lowermost) lie retropleurally against the corresponding costal heads. Some presynaptic fibers, in particular in the upper thoracic segments, ascend in the sympathetic chain and synapse with postganglionic sympathetic neurons of the superior, middle, and inferior cervical ganglia. Usually, the inferior cervical and T1 ganglia fuse to form the stellate (cervicothoracic) ganglion. Rarely is the T2 ganglion incorporated into the stellate ganglion as well. Two or more rami communicans, white (myelinated) and gray (nonmyelinated), connect each ganglion with its corresponding spinal nerve. At its origin, each ventral ramus of the spinal neves receives a gray ramus communicans from the corresponding sympathetic ganglion with efferent, postganglionic sympathetic nerves. A single preganglionic neurons for wide dissemination and possibly amplification. These postanglionic neurons are distributed to effector organs in various ways (Fig 1B): (a) they may return to the spinal nerve via a gray ramus communicans, to be distributed through ventral and dorsal spinal rami to sweat glands and blood vessels; (b) they may pass directly to a particular viscera (heart, tracheobronchial tree, ets.) via a medial branch of the sympathetic ganglia; or (c) they may ascend (usually) or descend before synapsing, and then leave the sympathetic chain as in (a) or (b). Peripheral autonomic activity is integrated at higher levels in the cerebrum and brainstem. Because of the relationship of the upper thoracic sympathetic chain with the target organs of the upper extremity and chest, upper thoracic sympathectomy has been known to have beneficial effects for angina, reflex sympathetic dystrophy (RSD), Raynaud's disease, and upper extremity ischemia [5], as well as hyperhidrosis. Severe hyperhidrosis usually manifests with excess sweating in the palms and feet, with or without axillary involvement, with the palmar involvement being the most common and debilitating. It appears that the T3 segment is not as important for sympathetic control of the hand as is T2 [6, 7] and this is confirmed by lack of palmar skin temperature changes after T3 ablation [8]. For AH, however, most surgeons take at least the T3 ganglion, and frequently the T4 ganglion as well [9-11]. All clinical series of PH show excellent clinical outcomes from upper thoracic sympathectomy far better than any form of nonsurgical treatment. In our series of those who had the sympathetic chain visualized and transected, 100% had marked improvement of their PH. There is no question that the lives of patients suffering from severe hyperhidrosis are radically changed by sympathectomy [12]. The advances of thoracoscopy over the past decade applied to upper thoracic sympathectomy yield a suprior operation in terms of visualization, morbidity, and postoperative pain compared to the open procedure. Clinical series comparing outcomes for PH compared to AH universally report less spectacular results achieved for AH [9-15]. Here, an important distinction must be made between those patients with primarily PH who have coexisting axillary sweating (and usually plantar hyperhidrosis as well), versus those patients for whom the primary indication for surgery is isolated AH. In our series of 180 prospectively questioned patients, 98 54.4%) had axillary sweating, and in 7 (3.9%) the AH was the worst and the primary indication for surgery. Of these 98 patients with some component of AH, sympathectomy gave 69.4% complete relief, and 5.1% no relief. However, if AH was the primary indication for sympathectomy (n = 7), the results were less satisfactory, with only 42.9% achieving complete relief, 28.6% partial relief, and 26.8% with no ultimate relief. Our finding of a higher rate of lack of relief of AH when the AH was the primary surgical indication was confirmed in other studies [9,10,13]. Ratees of dissatisfaction and regret with the procedure were higher for AH than PH (up to 11% to 20% [9,13]) and this was attributed not only to decreased effectiveness, but also to higher incidence of CH and gustatory hyperhidrosis. In these studies, the T4 as well as T3 ganglia were taken, and in our estimation there is no convincing evidence that taking T4 adds effectiveness to the sympathectomy for AH. In fact, more extensive sympathectomy may predispose patients to worse compensatory hyperhidrosis [2, 16, 17].

Catastrophic complications can occur from thoracoscopic sympathectomy. One report [18] discusses 2 cases of delayed recognition of tension pneumothorax from left side CO2 insufflation, leading to fatal and disabling consequences. If arrythmias or hemodynamic compromise occur while maintaining CO2 pneumothorax during intrathoracic gas. The left side appear far more susceptible to hemodynamic compromise from CO2 insufflation, and nearly all instances in our series occurred on the left side. Intrathoracic pressures above 15 mm Hg should only be used with utmost caution and vigilance, and communication between the surgeon and the anesthesiologist should be prompt and precise. In the right hemithorax, the number and size of veins adjacent to the upper sympathetic ganglia are much greater than on the left, and surgical techqique may need to be altered accordingly. Pneumothorax was found in 4 of our male patients. In no case had there been any suspicion of visceral pleural violation. Some or all of these cases of postoperative pneumothorax may be related to unrecognized bleb disease intrinsic to the patient rather than the procedure.

Hereditary transmission of the hyperhidrosis disorder clearly occurs with about half of our patients having some family history of hyperhidrosis. An interesting phenomenon was the marked and often spectacular provocative effect of hand lotion in elicting PH, occurring in 76.5% of our patients. Most of these patients developed simultaneous plantar hyperhidrosis with lotion application to the hands, lending credence to a centrally mediated feedback loop between palmar and plantar hyperhidrosis. The interesting phenomenon of "rebound sweating" 9 days occurred in 11.8% of our patients examined beyond the third postoperative day. This obscure, transient hyperhidrosis of the target organ typically occurred postoperative day 3 to 4, and lasted only about a day. One other report vaguely mentions its presence in 30 to 40 % of patients within the first 1 to 2 weeks postoperatively lasting less than one day, and acknowledges the obscure nature of this "last outpouring" 9 days of sweat [11]. Bilateral outpatient thoracoscopic sympathectomy is safe and effective when performed by properly trained surgeons and anesthesiologists, and when used for the correct indications has excellent results in the vast majority. Severe PH is the ideal indication for the procedure with cures in virtually all who have successful sympathetic transection at the level of T2. AH is not nearly so clear cut and the possible risk of unsatisfactory outcome in terms of AH relief and risk of compensatory hyperhidrosis must be clearly stated to patients. When plantar hyperhidrosis exists in conjunction with PH, sympathectomy reduces the plantar sweating in most patients, although it may rarely be worsened. Although bilateral thoracoscopic sympathectomy in the outpatient setting is safe and effective, the magnitude of the procedure must never be minimized, and hospital admission should be prompt for any suspect or complicated cases.

REFERENCES

1. Moran KT, Brady MP. Surgical management of primary hyperhidrosis. Br J Surg 1991;78:279-83.
2. Cohen Z, Levi I, Pinsk I, Mares AJ. Thoracoscopic upper thoracic sympathectomy for primary palmar hyperhidrosis-the combined paediatric, adolescent, and adult experience. Eur J Surg 1998;Suppl 580:5-8.
3. Hughes J. Endothoracic sympathectomy. Proc R Soc Med 1942;35:585-6.
4. Drott C, Gothberg G, Claes C. Endoscopic procedures of the upper thoracic sympathetic chain. A review. Arch Surg 1993;128:237-41.
5. Claes G, Drott C, Gothberg G. Thoracoscopy for autonomic disorders. Ann Thorac Surg 1993;56:715-16.
6. Hyndman OR, Wolkin J. Sympathectomy of the upper extremity: Evidence that only the second dorsal ganglion needs to be removed for complete sympathectomy. Arch Surg 1942;45:145-55.
7. Atlas LN. The role of the second thoracic spinal segment in the preganglionic sympathetic innervation of the human hand--surgical implications. Ann Surg 1941;114:456-61.
8. Chuang T-Y, Yen Y-S, Chiu J-W, et al. Intraoperative monitoring of skin temperature changes of hands before, during, and after endoscopic thoracic sympathectomy using infrared thermograph and thermometer for measurement. Arch Phys Med Rehabil 1997;78:85-8.
9. Rex LO, Drott C, Claes G, Gothberg G, Dalman P. The Boras experience of endoscopic thoracic sympathicotomy for plamar, axillary, facial hyperhidrosis and facial blushing. Eur J Surg 1998;Supp1 580:23-26.
10. Han PP, Gottfried ON, Kenny KJ, Dickman CA. Biportal thoracoscopic sympathectomy: surgical techniques and clinical results for the treatment of hyperhidrosis. Neurosurg 2002;50:306-12.
11. Drott C. Highlights from the discussions. Eur J Surg 1998;Supp1580:47-50.
12. Sayeed RA, Nyamekye I, Ghauri ASK, Poskitt KR. Quality of life after transthoracic endoscopic sympathectomy for upper limb hyperhidrosis. Eur J Surg 1998;Suppl 580:39-42.
13. Zacherl J, Huber ER, Imhof M, Plas EG, Herbst F, Fugger R. Long-term results of 630 thoracoscopic sympathicotomies for primary hyperhidrosis: the Vienna experience. Eur J Surg 1998;Suppl 580:43-46.
14. Edmondson RA, Banerjee AK, Rennie JA. Endoscopic transthoracic sympathectomy in the treatment of hyperhidrosis. Ann Surg 1992;215:289-93.
15. Bryne J, Walsh TN, Henderman WP. Endoscopic transthoracic electrocautery of the sympathetic chain for palmar and axillary hyperhidrosis. Br J Surg 1990;77:1046-9.
16. Shelley WB, Florence R. Compensatory hyperhidrosis after sympathectomy. N Engl J Med 1960;24:1056-8.
17. Bonjer HJ, Hamming JF, du Bois NA, van Urk H. Advantages of limited thoracoscopic sympathectomy. Surg Endosc 1996;10:721-3.
18. Cameron AEP. Complications of endoscopic sympathectomy. Eur J Surg 1998;Suppl 580:33-35.