Thoracoscopic bilateral dorsal sympathectomy for primary palmo-axillary hyperhidrosis short- and mid-term results.

BACKGROUND: Thoracoscopic bilateral dorsal sympathectomy is the standard of care for primary palmo-axillary hyperhidrosis. This study aims at studying the surgical outcomes with special emphasis on the incidence of compensatory hyperhidrosis (CH) after thoracoscopic dorsal sympathectomy. Post-procedural patient satisfaction as well as quality of life was measured and analysed.
MATERIALS AND METHODS: This is a retrospective analysis of sixty thoracoscopic dorsal sympathectomy surgeries in thirty patients in a tertiary level thoracic surgery centre over 2 years. Various peri-operative variables were recorded and assessed. Incidence of CH was noted and analysed in relation to patient satisfaction and record was made of quality of life at the time of discharge, at 3 months and 1-year follow-up following surgery.
RESULTS: We performed sixty video-assisted thoracoscopic sympathectomies in 30 patients. The mean operative time was 44.93 ± 10 min. The mean hospital stay was 1 day. There were no immediate post-procedural complications. All the patients had complete resolution of palmar and axillary hyperhidrosis. Fifty per cent of our patients (15/30) had some degree of CH after surgery. Quality-of-life measurement showed very good satisfaction by 100% at discharge, by 93.3% at 3 months and at 1 year. Those 6.66% of patients were partially satisfied/not satisfied because of the presence of moderate-to-severe CH.
CONCLUSION: A significant percentage of the patients with primary palmo-axillary hyperhidrosis will be very satisfied with the procedure at 1 year after surgery despite 50% of them developing CH. Detailed counselling regarding CH in the pre-operative period would minimise the dissatisfaction rate after surgery.

INTRODUCTION

Hyperhidrosis is defined as excessive sweating affecting daily activities of a person which eventually leads to social and psychological problems. The cause can be attributed to abnormal stimulation of the sweat glands by the sympathetic chain at T1 to T5. Primary is idiopathic and secondary follows a definitive cause. Sympathectomy remains the treatment of choice for primary hyperhidrosis.[1]

Historically, the first sympathectomy was done to treat an epileptic patient in 1889 by Alexander.[2] Kotzareff in 1920 did the first sympathectomy to treat hyperhidrosis.[3] First, thoracoscopic sympathectomy was published by Hughes in 1942.[4] Sympathectomy nowadays is performed by video-assisted thoracoscopy and has proven benefits to label it better than open surgery for the same. Currently, the main indication for endoscopic thoracic sympathectomy (ETS) is primary palmar hyperhidrosis but can be extended to axillary and facial hyperhidrosis too. Other indications of ETS are some specific cardiologic disorders such as angina, arrhythmias, cardiomyopathy and few pain syndromes of the upper limb.[5]

Herein, we aim to report the surgical outcomes of bilateral thoracic sympathectomy with special emphasis on incidence compensatory hyperhidrosis (CH). Post-procedural patient satisfaction as well as quality of life was measured and analysed.

MATERIALS AND METHODS

This study is a retrospective analysis of prospectively maintained data. Between March 2017 and March 2019, 60 thoracoscopic sympathectomies were performed for palmo-axillary hyperhidrosis on 30 patients in a tertiary care centre in New Delhi, India. This study included patients only with palmo-axillary hyperhidrosis, whereas patients with plantar hyperhidrosis were excluded from the study. Patients who were included in the study had excessive sweating in hands and armpits, with impairment of their work or social activities. All patients underwent a careful pre-operative evaluation through a detailed clinical history and examination along with routine blood examination and chest X-ray. Written informed consent from all patients was obtained before surgery. This study is approved by the Institutional Ethical Committee.

Surgical technique

Surgery was performed in general anaesthesia by the same surgeon with double-lumen endotracheal intubation and selective one-lung ventilation. Operation was done with patients in semi-sitting position with arms abducted >90°. All procedures were performed using a standard two-port access. Two small 5-mm incisions were made one at the superior margin of areola and other in fourth intercoastal space in midaxillary line. Five millimetre, 30° thoracoscope, 5 mm endoscopic dissector and 5 mm endoscopic hook were used in dissection. Sympathetic chain was identified by its location on the neck of ribs. After incising the parietal pleura, the sympathetic chain was exposed, recognising the third (R3) and fourth ribs (R4). The chain was interrupted using electrocautery at the upper border of the third rib and the lower border of the fourth rib and the intervening segment of the chain was removed [Figure 1]. A 16 F chest tube was placed through the midaxillary port incision and connected to a water seal. The procedure was repeated on other side the chest tubes were removed 1 h after surgery. Histopathological examination of all operative specimens was performed. Patients’ characteristics and clinical data including operating time, hospital stay, post-operative complications such as pneumothorax, hemothorax or Horner syndrome were analysed.

Figure 1

Intraoperative image compilation of thoracoscopic sympathectomy (a) Thoracoscopic anatomy of right sympathetic chain, (b) Division of pleura over the sympathetic chain, (c) Complete isolation of sympathetic chain, (d) Resection of sympathetic chain

CH is defined as a new pattern of excessive sweating after sympathectomy, which starts impairing the daily activities of a person.[5] Major areas of occurrence are loins, back, thighs and/or groin regions. It is classified as mild, moderate and severe where mild is small amount of sweating usually tolerable, initiated by triggers like ambient heat, stress or physical activity – which does not embarrass the patient and does not require a change of clothes. Moderate CH is when the amount of sweat is higher, but still, it does not embarrass the patient nor requires changing clothes. Severe CH is defined if the sweat amount is copious with high flow requiring one or more change of clothes. CH as mild, moderate and severe and recurrence of symptoms were evaluated at the time of discharge, 3 months and 1 year post surgery by clinical history and physical examination.[6]

Patient satisfaction and quality of life measurements

Patients were divided into four groups: very satisfied (completely satisfied with the improvement of their quality of life after sympathectomy without any complaints), satisfied (who were happy with the improvement of their quality of life even with the development of minor complaints), partially satisfied (no improvement of their quality of life after sympathectomy and also development of minor complaints) and patients who will not recommend sympathectomy to other patients (dissatisfied due to worsening of their quality of life after sympathectomy with the development of major complaints in follow-up period). Patients were divided into these four groups in follow-up visits at the time of discharge, after 3 months and after 1 year of surgery using a visual analogue scale (VAS): very satisfied (VAS score of 9–10), satisfied (VAS score of 6–8), partially satisfied (VAS score of 3–5) and not recommending this operation to other patients (VAS score of 0–2)[7] [Figure 2].

Figure 2

Schematic representation of the study methodology

Statistical methods

Statistical analysis was carried out using Stata 14.0 software (StataCorp LLC, Texas, USA). Continuous variables were presented as mean with standard deviation. Categorical variables were expressed as frequencies with percentages.

RESULTS

Demographic details are given in Table 1. We performed 60 video-assisted thoracoscopic sympathectomies in 30 patients. There was no conversion or post-operative mortality. The mean operative time was 44.93 ± 10 min. All chest tubes were removed on the day of surgery. The mean hospital stay was 1 day. None of the patient had any pneumothorax after surgery. All patients were fully satisfied having warm and dry hands and axilla in immediate post-operative period. No patient experienced Horner’s syndrome [Table 2]. There was mild CH in 2 patients at the time of discharge. Mild CH was reported in 10, moderate in 3 and severe in 2 patients at 3 months post discharge. At 1 year after discharge, 12 patients reported mild CH, while 2 patients had moderate CH and in 1 patient, it was severe. Hence, 50% of our patients (15/30) had some degree of CH after ETS [Table 3]. No recurrence was noted in the follow-up period. All the patients had complete resolution of palmer hyperhidrosis.

Table 1

Demography and clinical distribution

Characteristics	Frequency
Mean age (in years)	25±2.6
Sex (M/F)	30/0 (100%/0%)
Palmar + Axillary hyperhidrosis (n)	30

Table 2

Perioperative and follow-up details

Characteristics	Frequency
Mean duration of surgery (in minutes)	44.93±10
Mean duration of hospital stay (in days)	1
Mean duration of chest tube (in days)	1
Complications	None
Median follow-up (in Months) (Range)	22.36 (12-36)

Table 3

Details of compensatory hyperhidrosis

Compensatory hyperhidrosis (CH)	At discharge	3 months	1 Year
Mild	2	10	12
Moderate	Nil	3	2
Severe	Nil	2	1
Total	2 (6.66%)	15 (50%)	15 (50%)

QoL measurements showed that 100% of patients were very satisfied after undergoing ETS at the time of discharge. At 3 months, 93.3% of patients were very satisfied, while 6.66% were partially satisfied because of the presence of severe CH. At 1 year from surgery, 93.33% of patients felt very satisfied, 3.33% felt satisfied and 3.33% felt like not recommending the surgery to anyone because of the presence of moderate-to-severe CH [Table 4].

Table 4

Patient satisfaction and quality of life (QoLI) at discharge, 3 months and 1 year after discharge using visual analog score

QoLI	At discharge	3 months	1 year
Very satisfied	30 (100%)	28 (93.33%)	28 (93.33%)
Satisfied	-	-	-
Partially satisfied	-	2	1
Not recommending operation to others	-	-	1

DISCUSSION

In the era when video-assisted thoracoscopic surgery (VATS) was not that prevalent, thoracotomy was the standard surgical approach for hyperhidrosis.[8910] In the past two decades, open surgery has been virtually replaced by VATS/thoracoscopy for hyperhidrosis owing to benefits such as lesser hospital stay, reduced morbidity, lesser pain and excellent cosmetic results.[1112] Most of the people understand thoracoscopic sympathectomy as a cosmetic procedure, but our data show that all who sought surgery were disabled professionally and socially by this excessive sweating. A significant majority of the patients in this study were very satisfied after surgery which improved their social life and work performance.

There was no occurrence of any pneumothorax or hemothorax in our series which are considered the most common post-operative complications in most of the series, this could be due to relatively smaller numbers and the fact that the pleural cavity was drained for 1 h after the procedure in all cases and also due to the experience of the team with thoracoscopic surgery.[1314] Another very well-documented complication of this surgery in other series is Horner’s syndrome due to injury to stellate ganglion which is not present in our series because of careful dissection of the sympathetic chain and proper identification of the level of sympathectomy which, in our case, was in accordance with STS consensus statement from top of R3 to bottom of R4 for best results.[15]

Our series had no recurrence or persistence of symptoms which is also the case with recent reports.[16] Few authors have reported early and late recurrences which they attributed to incomplete sympathectomy or nerve regeneration. Misidentification of the sympathetic chain due to local anatomic variations is a major cause of recurrence.[141718]

Incidence of CH varies markedly in the literature, from 3% to 98%.[15] In our series, the overall incidence of CH was 50% with 10, 3 and 2 patients having mild, moderate and severe CH, respectively, at 3 months post surgery. This changes to 12, 2 and 1 at 1 year post surgery. Previous studies suggest that the higher level of the sympathetic chain transection (R2 especially) and more levels transected corresponded to a greater the risk of compensatory sweating. Few authors reported compensatory hyperhidrosis in almost all patients even after limited sympathectomy.[1920] On the other hand, there are reports that suggest that the extent of thoracoscopic sympathectomy did not affect the incidence of CH.[1319]

Our experience is that it is very hard to predict which patients will develop CH and to what extent will be the severity. Nonetheless, the risk can be reduced by avoiding R2 sympathectomy and limiting the number of levels of interruptions. In our patients who developed moderate-to-severe CH, a multipronged approach was utilised with psychological counselling, strict weight control, avoidance of excessively hot environments and using ‘breathable’ fabrics/clothes. Anticholinergic agents, benzodiazepines and beta-blocker agents were used with some efficacy and they were advised to restrain from sweat-stimulating things like alcohol. They were also advised to use topical preparations and antiperspirants. This resulted in downgrading of severity of compensatory hyperhidrosis in 2 patients. Sympathetic chain reconstruction was also thought in one case which showed severe CH post 1 year of surgery but was not tried because of too fragile results of only a few anecdotal reports.[2122]

The most important factors affecting a patient’s quality of life post surgery are his control of initial symptoms which are mainly palmar hyperhidrosis which is evident in our study by all 30 patients reporting them to be very satisfied during discharge as all of them had dry hands at that time. Three months postoperatively, the patients having severe CH reported to be just partially satisfied of surgery, but even at that time, all other patients who were having mild-to-moderate CH still reported to be very satisfied of surgery. A similar trend continued 1 year post surgery when one patient who was still having severe CH reported that he would not recommend this surgery to anyone. Other whose severity of CH had decreased from severe-to-moderate because of medical measures reported partial satisfaction and all other patients reported to be very satisfied of surgery. Hence, the overall rate of very satisfied patients in our study was 93.33% 1 year post surgery which is in accordance with other previous reports.[23] This high rate of satisfaction makes it an excellent option for hyperhidrosis patients. However, one must bear in mind that this procedure is mainly intended to improve the lifestyle of the patient, and hence, all patients need to be adequately counselled about the risks and incidence of post-operative CH and the decision to get the procedure done should primarily be theirs.

CONCLUSION

This study concludes that a significant majority of the patients with primary palmo-axillary hyperhidrosis will be very satisfied with the procedure at 1 year after surgery despite 50 percent of them developing CH. However further studies with larger number with and longer follow up are needed to further evaluate this procedure and to better understand the mechanism of CH.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.