Differens options in thoracoscopic
sympathectomy
Hans Pilegaard, Ass. Prof, MD
Department of Cardiothoracic SurgeryAarhus University Hospital, Skejby
Denmark
13th Turkish Thoracic Society CongressIstanbul Turkey
Hyperhidrosis
Strutton et al. J Am Acad Dermatol 2004; 51:241-248
National questionnaire 150.000 householdsUS prevalence 2.8%
7.8 millions individuals
4 millions axillarwork
emotionalpsychologicalsocial
Hyperhidrosis
• Blushing• Facial• Palmar• Axillary• Foot
• Raynaud syndrome• Cardiac arrhytmia?• Angina pectoris?
Thoracoscopic treatment
Topical
Aluminium chloride (AlCl3-6H2O)
Anticholinergic agentsAstringent agents (Glutaraldehyde, formalin)IontophoresisBotulinum toxin
Excision of glands in the axillary regionLiposuctionLaser treatment
Thoracotomy Kotzareff 1920 Kotzareff A. Rev Med Suisse Romande 1920; 40:111-
113
Supraclavicular approach Telford 1935Telford E. Br J Surg 1935; 23:448-450
Anterior approach Polumbo 1956Polumbo LT. Arch Surg 1956;72:659-66
Transaxillary Goets & Marr 1944Goets R, Marr J. Clinical Proceedings 1944; 3:102-114
Posterior Adson 1929Cloward 1969Cloward. J Neurosurgery 1969; 30:545-551
Axillar extrapleural Roos 1971Roos D. Ann Surg 1971; 173:429-442
Open sympathectomy
Thoracoscopy Hughes 1942Hughes J. Proc Royal Soc Med 1942; 35:585-586
Thoracoscopy Goets & Marr 1944Goets R, Marr J. Clinical Proceedings 1944; 3:102-
114
Thoracoscopy Kux 1946-54Kux E. Georg Thieme Verlag, Stuttgart 1954
VATS 1980´s -
Thoracoscopic sympathectomy
Thoracoscopic sympathectomy
EasyFast (minuttes)Good visualizationSmall incisions
OutpatientAwakeLocal anaestesia
Elia et al. Awake one stage bilateral thoracoscopic sympathectomy for palmar hyperhidrosis: A safe outpatient procedure. 2nd EACTS/ESTS joint meeting, Leipzig, Germany 2004
Definitions
• Sympathotomy– Transection
• Sympathectomy– Resection– Ablation
Thoracoscopy
• Needle, 5mm, 10mm
• Uniportal• 2 ports• 3 ports can be necessary
Methods
• Electrocoagulation• Harmonic scalpel• Laser• Clipping
– Reversal
Electric vs harmonic scalpel
• Non randomized prospective• N=1515 patients• 24 hours, 7 days and 30 days• Responserate: 90%/68%/27%• No difference either by method or
level
de Campos JR et al. ICVTS: in press JR
Clipping
• N=727 patients – responsrate 92%• T2: 399, T2+3: 55, T3+4: 273• 34 patients have had clip removed• T2: 21, T2+3: 7, T3+4: 6 • 15 patients. decrease in
compensatory sweating
Sugimura H et al. J Thor Cardiovasc Surg 2009;137(6): 1370-8
Supine Single lumen tube
Harmonic scalpelTwo ports
Method
Reverse Trendelenburg
Blushing Th 2
Palmar Th 2-3 Axillary Th 2-3-4
Sympathectomy level
Sympathicotomy - left
Facial blushing and hyperhidrosis
T1-T2-T3 Drott et al. Br j Dermatol 1998;138:639-43.
T2 Kim et al. Eur J Cardiothor Surg 2004;26:396-400
Doolabh et al. Ann Thor Surg 2004;77:410-4Dewey et al. Ann Thor Surg 2006;81:1227-33Chou et al. Surg Endoscpo 2006;20:1749-53Licht et al. Ann Thor Surg 2006;81:1863-6Weksler et al. Thorac Surg Clin 2008;18:183-191
T2-T3 Drott et al. J Cosmet Dermatol 2000;1:115-9
Licht et al. Ann Thor Surg 2006;81:1863-6
Facial blushing and hyperhidrosis
• Follow-up questionaire – 2 centers• N=189 • Responsrate 96%• Outcome similar• Compensatory sweating• T2 83% - T2-3 95% p=0.02
Licht et al. Ann Thor Surg 2006;81:1863-6
Facial blushing
• RCT• T2 vs T2-T3• Study size n=200• N= 55• No difference
+200 papers
Most recommend T2-T3
Palmar hyperhidrosis
Chiou TS & Chen SC. Br J Surg 1999; 86:45-47Reisfeld R et al. Surg Laparosc Endosc Percutan Tech 2002; 12:255-267Kao MC. Ann Thorac Surg 2001; 72:667-668Andrews & Rennie JA. Br J Surg 1997; 84:1702-1704Lin CC. Surg Endosc 1990; 4:224-226
T2
Dumont P et al. Ann Thorac Surg 2005; 78:1801-1807 Zacherl J et al. Ann Thorac Surg 1999; 68:1177-1181 Gossot D et al. Ann Thorac Surg 2003; 75:1075-1079
Yilmaz EN et al. Eur J Cardiothorac Surg 1996; 10:168-172Lardinois D & Ris HB. Eur J Cardiothorac Surg 2002; 21:67-70Nicholson ML et al. Ann R Coll Surg Engl 1994; 76:311-314
T2-T4
T2-T5
T2 vs T3Palmar hyperhidrosis
• N= 60 patients• Succesrate: 59/60• Compensatory hyperhidrosis
– No differens in number, but in severity
– T2/T3: 13/4 p= 0.007
Yazbek G et al: Clinics 2009;64(8):743-9Yazbe
T3 vs T2-T4Palmar hyperhidrosis
• N= 232 patients
Compensatorysweating
T2-4N=115
T3N=117
p
N= 33 25
Mild 15 12
Moderate 7 9
Severe 11 4 < 0.05
Xu Li et al. Ann Thor Surg 2008;85:1747-52
Axillary hyperhidrosis
T2-T4 Zacherl J al. Ann Thorac Surg 1999; 68:1177-1181Hsu CP et al. Arch Surg 2001; 136:1115-1117Dumont P et al. Ann Thorac Surg 2005; 78:1801-1807 Rex LO et al. Eur J Surg Suppl 1998;23-26 Drott C & Claes G. Cardiovasc Surg 1996; 4:788-790 Ahn SS et al. Ann Vasc Surg 2000; 14:415-420
T2-T3 Fox AD et al. Eur J Vasc Endovasc Surg 1999; 17:343-346Andrews BT & Rennie JA. Br J Surg 1997; 84:1702-1704Kao MC et al. Ann Acad Med Singapore 1996; 25:673-678
T2 Chiou TS & Chen SC. Br J Surg 1999; 86:45-47
T4 vs T3-4Axillary hyperhidrosis
• N= 64 patients• RCT
Compensatory sweating
T3-4 T3 p T3-4 T3 P
Mild 16 14 18 13
Moderate
11 2 < 0.001
11 1 < 0.001
6 mdr 12 mdr
Munia MAS et al. Clinics 2008;63(6);771-4
Compensatory sweating
• N=158 patients• Responsrate 89%
– T2 facial blushing and hyperhidrosis– T2-3 palmar hyperhidrosis– T2-4 axillary hyperhidrosis
Level of sympathectomy
Severe sweating %
T2 21
T2-3 36
T2-4 49
Licht et al. Ann Thor Surg 2004;78:427-31
P=0.04
Gustatory sweating
• N=238 patients• Responsrate 96%• Gustatory sweating 32%
Level of sympathectomy
Gustatory sweating %
T2 27
T2-3 29
T2-4 44
Licht et al. Ann Thor Surg 2006;81:1043-7
P=0.04
Information to the patient
• Succes rate• Sideeffects
– Compensatory sweating– Gustatoric sweating– Horner’s syndrome– Heart rate
• Definitiv operation• Telarenta T. Eur J Surg Suppl 1998;580:17-8
Succesrate
• Facial blushing and hyperhidrosis 90%
• Palmar hyperhidrosis100%
• Axillary hyperhidrosis 80%
Sideeffects
• Compensatory sweating 90%• Gustatoric sweating 35%• Horner’s syndrome > 1%• Heart rate at rest 10%
• Dry hands
• Return to basic not a possibility
Side effect - Harlequin
Eur J Cardiothor Surg 2010;37:959
• 1997-2007• N=669• 48 reoperation
Number
Improved
Unilateral 29 96%
Bilateral 6 50%
recurrence 13 75%80% compensatory sweating38% worsening
Licht et al. Ann thor Surg 2010;89:1087-90
Conclusion
T2 for facial blushing and hyperhidrosis
T3 for palmar hyperhidrosis
T4 for axillary hyperhidrosis
Conclusion
Most patients are satisfied with the operation
90% of the patients will get compensatory sweating
Signifikant compensatory sweatingis more frequent after
T2-4 sympathectomi for axillary hyperhidrosis
Good information before the operationis mandatory
Conclusion