Keywords hyperhidrosis - video-assisted thoracoscopic surgery - sympathetic nerve - ramicotomy
Introduction
Severe primary hyperhidrosis is commonly associated with excessive sweating beyond
physiological needs, thereby especially affecting the palmar, plantar, and axillary
regions.[1 ]
It has been clearly shown that it influences many aspects of patient's life. The psychosocial
impact leading to difficulties in social life, at work, at school, and through daily
activities is significant.[2 ] Surgery of the sympathicus chain was first introduced in the 19th century for the
treatment of an epileptic patient.[3 ] However, the first sympathectomy for hyperhidrosis was performed in 1920.[4 ] With the development of minimally invasive procedures, Hughes reported the first
thoracoscopic sympathectomy in 1942.[5 ] Since then, the surgery of the sympathetic nerve has developed progressively and
the knowledge on the physiology on the sympathetic nerve has evolved. Several surgical
approaches have been developed to treat patients with severe palmar, axillary, and
plantar hyperhidrosis. However, it remains unclear which the ideal procedure is, especially
to avoid the undesirable postoperative complication of compensatory or recurrent sweating.[6 ]
[7 ]
[8 ]
[9 ] Here, we report our initial experience using selective sympathetic ramicotomy for
patients suffering from severe therapy-refractory palmar and axillary primary hyperhidrosis,
which was performed through a novel miniuniportal video-assisted thoracoscopic surgery
(VATS) approach. Furthermore, we demonstrate the long-term efficacy.
Patients and Methods
Between January 2014 and October 2017, a total of 51 patients (n = 37 females) with severe essential palmar and/or axillary hyperhidrosis were prospectively
enrolled in this study and data were recorded. The mean age was 30 years (range: 12–64
years). All patients were consented to the study preoperatively. Exclusion criteria
were defined as: age < 15 years, pregnancy and excessive sweating due to a specific
health issue such as late onset of sweating combined with the presence of comorbidities
or the use of medication known to be associated with sweating.
Prior to surgery, all patients underwent various nonsurgical therapies such as topical
application of aluminum chloride, iontophoresis, oral anticholinergics, and botulinum
toxin injection, which all failed or lead to recurrent sweating within 3 months. Primary
end point of this study was the postoperative absence of palmar and axillary sweating
at 4 weeks after the surgical procedure. Secondary end points included the duration
of surgery, hospital stay, length of chest tube therapy, and compensatory sweating.
All patients were postoperatively evaluated 4 weeks after surgery. Further follow-up
was performed by telephone questionnaire.
Surgical Technique
Bilateral miniuniportal VATS ramicotomy ([Video 1 ]) was performed through a 1-cm incision at the middle of the transverse axillary
line via the third intercostal space ([Fig. 1 ]). A 5-mm trocar was inserted into the thoracic cavity to guide the 5 mm thoracoscope.
[Fig. 2 ] presents the sympathetic chain with the rami communicantes of the sympathetic ganglions.
Through the same incision, a 5-mm endoscopic, monopolar, electrocautery hook was inserted.
After visual identification of the sympathetic chain, the parietal pleura was incised
with 5 to 10 mm distance from the main sympathetic chain. Further on, the rami communicantes
(Th2–Th5) were transected with electric cautery in 5 mm distance from the sympathetic
ganglion. Thereby, the main sympathetic trunk remained intact. The intercostal space
and its neurovascular structures were also preserved ([Fig. 3 ]). [Fig. 4 ] shows the preserved sympathetic chain at the end of the ramicotomy.
Fig. 1 Video-assisted thoracoscopic surgery through a 1-cm incision for inserting a 5-mm
trocar and 5-mm electrocautery device.
Fig. 2 The sympathetic chain (red triangle) and the rami communicantes (red arrows) as well
as the second till fifth rip. This serves as anatomic landmarks for defining the area
of resection.
Fig. 3 The intercostal space and its neurovascular structures, which were also preserved
after ramicotomy.
Fig. 4 Preserved sympathetic chain after resection of the rami communicantes from the second
ganglion to the fifth ganglion.
Video 1 Video session demonstrating intraoperative steps for thoracoscopic selective ramicotomy:
Using single lung ventilation of the opposite lung, the thoracic sympathetic chain
is visualized. Additionally, in support of lung deflation and to achieve an excellent
view, the lung is gently pushed forward using a thoracoscopic sponge stick. The sympathetic
chain with the rami communicantes is now identified from the second to the fifth rib
after identification of the levels using a hook to palpate the ribs. After that, the
parietal pleura overlying the main sympathetic chain is incised from Th2 to Th5 using
an endoscopic, electric cautery hook. With the sponge stick, the main sympathetic
chain is gently pulled down. After visual identification, the rami communicantes will
be transected from Th2 to Th5 using electric cautery. At the end of the ramicotomy,
the main sympathetic chain and the neurovascular structured are preserved. For pain
assessment, carbostesin 0.25% is injected into the intercostal space.
Results
Preoperative, severe palmar sweating was presented in 51 patients; 26 patients suffered
simultaneously from severe palmar and axillary sweating. From the 51 patients, 28
patients presented additionally with severe or moderate plantar sweating. The location
of hyperhidrosis is summarized in [Table 1 ]. In all patients, the intra- and postoperative courses were uneventful. One patient
required chest tube drainage for 5 days due to prolonged air leak. The mean duration
of bilateral surgery was 67 ± 2.5 minutes. The mean hospital stay was 2 ± 1 days.
Chest tubes were removed after no air leakage was detected by the digital system with
a postoperative mean duration of 1 day (range: 0–5 days). After chest tube removal,
chest X-ray did not show any evidence for pneumothorax or pleural effusion in all
patients. After the procedure, all patients experienced total palmar and axillary
dryness. Interestingly, in 10 female patients, plantar sweating diminished completely,
which was not expected. At the time of discharge, all patients reported warm and dry
hands and axillae. This was identical with findings at 4 weeks after surgery, where
no evidence of recurrent palmar or axillary sweating was seen. Furthermore, none of
the patients reported evidence of compensatory sweating. Moreover, further follow-up
did not show any palmar and axillary sweating or compensatory sweating. The mean follow-up
was 12 ± 2.5 months after surgery.
Table 1
Location of sweating
Location of sweating
%
Number of patients
Palmar
100
51
Palmar and axillary
51
26
Palmar and plantar
55
28
Palmar, axillary, and plantar
35
18
Discussion
Primary hyperhidrosis is a pathological state of excessive sweating potentially affecting
different regions especially the hands, the axilla, and the feet. Genetic predisposition
was discussed.[10 ] A variety of nonsurgical treatment options such as the application of anticholinergic
drugs, botulinum toxin A injection, iontophoresis, aluminum-based antiperspirants,
and laser therapy were described for treating primary hyperhidrosis and are routinely
applied initially.[11 ] However, in a certain number of patients, these conservative approaches fail or
lead to early recurrence. In this study, all patients underwent intensive conservative
therapy managed by a dermatologist for several months, but did not show any remarkable
improvement of their sweating. Patients were then introduced to the option of surgical
therapy.
Surgical techniques for primary hyperhidrosis regarding the sympathetic nerve have
developed continuously during the past decades. Techniques to interrupt the sympathetic
chain are well described and vary from sympathectomy, “sympathicotomy” or “sympathotomy,”
sympathetic block to ramicotomy. The surgical term of “sympathectomy” presents the
dissection of a specific part of the sympathetic trunk and ganglia. It was widely
spread and a standard during the initial open surgical approaches. Today, the most
frequently used technique is the “sympathicotomy” or “sympathotomy,” which is based
on the interruption of the sympathetic trunk only by its complete transection, using
electrocautery, endoscopic scissors, or other devices.[12 ]
[13 ]
[14 ] Furthermore, the sympathetic block is performed using metallic clips, which are
applied across the sympathetic nerve without transection.[6 ] However, the most effective and least invasive surgical approach is not clearly
defined. An alternative is the ramicotomy, where the sympathetic rami communicantes
of the sympathetic ganglions are selectively resected, while preserving the thoracic
sympathetic ganglia and the nerve chain.[8 ] This has been reported to reduce compensatory sweating. However, some studies report
a higher recurrence rate.[15 ]
With regard to the anatomic level of nerval interruption of the sympathetic chain,
several studies suggested multiple levels. It has been reported that spinal segments
3 to 6 seem to be the origin of the preganglionic fibers reaching the arm and hand.
Especially, the third and fourth segments are the most dominant origins.[16 ] Yazbek et al compared the effects of sympathectomy at T2 and T3, addressing that
sparing the T2 ganglion might decrease the risk of compensatory sweating.[17 ] Other studies reported that isolating the T3 and T4 ganglions may lead to acceptable
results in the treatment of palmar hyperhidrosis. However, the rate of compensatory
sweating in these studies varies.[18 ]
[19 ]
[20 ] Therefore, the Society of Thoracic Surgeons has published a consensus paper for
the surgical treatment of hyperhidrosis based on a broad review of the literature.
The report suggested a standardized surgical approach for primary hyperhidrosis. Moreover,
the exact sympathetic nerve levels for interruption according to the corresponding
sweating regions were defined.[21 ] Interruption at R4 to R5 levels is supposed to be the most effective in patients
suffering from palmar and plantar hyperhidrosis. Patients with isolated axillary hyperhidrosis
should be exposed to nonsurgical treatment options before they undergo surgical procedures.
However, if treatment fails and patients are subjected to surgery, R4 to R5 interruption
is recommended. Furthermore, for facial blushing/hyperhidrosis, R2 to R3 interruption
is suggested to be the most effective surgical approach but with increased risk for
compensatory sweating.
Regardless of the previously reported experience and therapy strategies, in our study,
the rami communicantes of the sympathetic ganglions were interrupted at the R2 to
R5 levels independently of the region of sweating. Therefore, patients with palmar
or axillary hyperhidrosis underwent the same surgical approach. However, patients
with only plantar sweating were not operated. The primary focus of the surgical approach
in this study was to treat predominantly palmar and/or axillary hyperhidrosis.
Gorur et al compared the outcome between patients who underwent T3/T4 sympathetic
clipping with those undergoing only T3 and T6 clipping. Both groups were compared
regarding compensatory sweating and recovery of plantar hyperhidrosis. Notably, compensatory
sweating rate was high in both groups, but recovery of plantar hyperhidrosis was higher
in patients with T3 and T6 clipping. This analysis revealed that clipping beyond the
thoracic level T6 could be effective in reducing plantar sweating.[22 ] Recently, Xiao et al evaluated the effect of VATS sympathectomy at the thoracic
level T4 on plantar hyperhidrosis for patients with palmoplantar hyperhidrosis with
follow-up after 1 and 6 months. Improvements in plantar hyperhidrosis were observed
initially in singular patients (28%, 8 out of 28 patients), but this improvement has
not sustained over a long period.[23 ] Till now improvement of plantar hyperhidrosis after selective ramicotomy of T2 till
T5 ganglion has not been reported. In our study, we observed an improvement in plantar
hyperhidrosis (n = 10 patients), without sweating recurrence during the follow-up period. This pathophysiological
finding, however, cannot be explained by the current scientific knowledge.
Although the interrupted levels were extensive in comparison to other studies, compensatory
sweating or even excessive sweating in other body regions were not observed. Even
in further follow-up, no recurrent or compensatory sweating was observed. Even though
we picked R2 to R5 for interruption on the level of rami communicantes, we fully preserved
the sympathetic chain as a difference.
Although a ramicotomy seems to be a well-tolerated surgical approach without any side
effects such as compensatory sweating and recurrent sweating, we address the following
limitations of this study. The number of patients recruited is limited and represents
our initial experience. Further studies on larger cohorts are needed to verify our
promising results. Also, a control group was not added, which is essential for further
investigations. Contrary to previous reports, we have achieved promising postoperative
results. Taking the limitation of this study into account, we now offer this unique
uniportal VATS approach to patients with severe palmar, axillary, and otherwise therapy-refractory
hyperhidrosis.
In conclusion, this surgical approach is safe, cosmetically most favorable and leads
to instant patient satisfaction and increase in quality of life in a cohort of individuals
that have gone through long-term treatments and are often accompanied by psychosocial
conflicts and depression.
