Alan E. P. Cameron

Specific complications and mortality of endoscopic thoracic sympathectomy

Endoscopic Thoracic Sympathectomy (ETS) has gained an increasing popularity due to its minimal invasive character. Despite the simplicity of the procedure, non-surgical options should always be considered as the first line of treatment. The complication risk of ETS is low but side effects, primarily compensatory sweating (CS) of mainly the trunk may be severe enough to cause regret of the procedure. The risk/benefit ratio should always be discussed with the patient. Severe palmar hyperhidrosis and facial blushing respond very well to ETS with a high patient satisfaction rate. Facial hyperhidrosis is effectively treated with ETS but is associated with a high risk for severe CS. Axillary hyperhidrosis is best treated by other means than ETS. The use of ETS for pain syndromes, vascular insufficiency and angina pectoris is not well supported by scientific evidence, making mandatory careful patient selection.

Thoracic sympathectomy: a review of current indications

BackgroundThoracic sympathetic ablation was introduced over a century ago. While some of the early indications have become obsolete, new ones have emerged. Sympathetic ablation is being still performed for some odd indications thus prompting the present study, which reviews the evidence base for current practice.MethodsThe literature was reviewed using the PubMed/Medline Database, and pertinent articles regarding the indications for thoracic sympathectomy were retrieved and evaluated. Old, historical articles were also reviewed as required.Results and conclusionsCurrently, thoracic sympathetic ablation is indicated mainly for primary hyperhidrosis, especially affecting the palm, and to a lesser degree, axilla and face, and for facial blushing. Despite modern pharmaceutical, endovascular and surgical treatments, sympathetic ablation has still a place in the treatment of very selected cases of angina, arrhythmias and cardiomyopathy. Thoracic sympathetic ablation is indicated in several painful conditions: the early stages of complex regional pain syndrome, erythromelalgia, and some pancreatic and other painful abdominal pathologies. Although ischaemia was historically the major indication for sympathetic ablation, its use has declined to a few selected cases of thromboangiitis obliterans (Buerger’s disease), microemboli, primary Raynaud’s phenomenon and Raynaud’s phenomenon secondary to collagen diseases, paraneoplastic syndrome, frostbite and vibration syndrome. Thoracic sympathetic ablation for hypertension is obsolete, and direct endovascular renal sympathectomy still requires adequate clinical trials. There are rare publications of sympathetic ablation for primary phobias, but there is no scientific basis to support sympathetic surgery for any psychiatric indication.

Sympathetic chain clipping for hyperhidrosis is not a reversible procedure

Sympathetic chain clipping for hyperhidrosis is not a reversible procedure. We compliment Dr. Loscertales et al. [1] for their excellent study, a very important addendum to our scientific knowledge of sympathetic ablation for the treatment of primary hyperhidrosis (HH). Blocking the sympathetic chain by clipping in patients with HH has been used for several years, in the belief that if intolerable compensatory hyperhidrosis (CHH) develops, unclipping allows reversal. Several clinical studies have been published that report a variable degree of reduction in CHH. In some of the ‘‘successful’’ reversals, palmar HH did not recur. One should bear in mind that the pressure exercised by a clip is reported to be enormous. In a study on the required burst pressures for a clip to slip from the vessel on which it was applied, values of 593–854 mmHg were needed [2]. Removal of a clip by pulling should by itself tear the encompassed tissue. Therefore, the puzzling aspects of the clinical results that have been published are not the failures, but the allegedly successful cases. The results of Dr. Loscertales et al. study further confirm this incompatibility. How can we explain the allegedly successful clinical reports? The pathophysiology of CHH is absolutely obscure. It is possible that unclipping exercises an important placebo effect. This is plausible, especially for those patients in whom recurrent HH is not observed. Is reoperation to remove applied clips justifiable in the light of current knowledge? The answer may be negative, and patients who are advised to have the clips removed should at least be informed that the basis for the offer is empirical and has no proven scientific ground. Further experimental studies are required to prove that in the long-term, there is no nerve regrowth through the clipped segment of the sympathetic chain.

Treatment options for primary hyperhidrosis.

We read with interest and we compliment Drs Walling and Swick for their thorough article on the ‘‘Treatment Options for Hyperhidrosis.’’ On behalf of the International Society of Sympathetic Surgery (ISSS), we would like, however, to present some additional comments about the surgical treatment of primary hyperhidrosis. There is no question that appropriate sympathetic ablation is the only option that can secure almost 100% permanent anhidrosis of the hands – provided the surgeon is competent and the method appropriate. The reason why there is a place for noninvasive treatments is because of the so-called compensatory hyperhidrosis, which is unpredictable and has no satisfactory treatment. There is a continuing debate in the literature on how to reduce and attenuate compensatory hyperhidrosis, and there is a trend today, adopted by many surgeons, to spare the T-2 ganglion in the belief that by doing so one achieves this goal. This belief has not, however, been substantiated by thoroughly reviewing the literature, and as was presented to the 9th International Symposium of Sympathetic Surgery (Odense, Denmark, June 2011). We feel that patients presenting with primary hyperhidrosis should receive the full spectrum of possible treatments, so we agree that the treatment algorithms suggested by Drs Walling and Swick are valid. However, bearing in mind the fact that appropriate surgery is the only means to permanently achieve anhidrosis (albeit with the complications and sequelae presented by the authors), we consider that some patientsmaywish to skip some of the less successful earlier stages.

The Etiology of Primary Hyperhidrosis: A Systematic Review

PurposePrimary hyperhidrosis is a pathological disorder of unknown etiology, affecting 0.6-5% of the population, and causing severe functional and social handicaps. As the etiology is unknown, it is not possible to treat the root cause. Recently some differences between affected and non-affected people have been reported. The aim of this review is to summarize these new etiological data.MethodsSearch of the literature was performed in the PubMed/Medline Database and pertinent articles were retrieved and reviewed. Additional publications were obtained from the references of these articles.ResultsSome anatomical and pathophysiological characteristics (as well as enzymatic, metabolic, and neurological dysfunctions) have been observed in hyperhidrotic subjects; three main possible etiological factors predominate. A familial trait seems to exist, and genetic loci associated with hyperhidrosis have been identified. Histological differences were observed in sympathetic ganglia of hyperhidrotic subjects: the ganglia were larger and contained a higher number of ganglion cells. A higher expression of acetylcholine and alpha-7 neuronal nicotinic receptor subunit in the sympathetic ganglia of patients with hyperhidrosis has been reported.ConclusionsDespite these accumulated data, the etiology of primary hyperhidrosis remains obscure. Nevertheless, three main lines for future research seem to be delineated: genetics, histological observations, and enzymatic studies.

Late results of endoscopic thoracic sympathectomy for hyperhidrosis and facial blushing (Br J Surg 2011; 98: 1719–1724)

Sir We have read the invited commentary to our article1 by Dr Flum. He is an authority in the field and we greatly appreciate his views. The sources of inaccuracy he raises, including patients lost to follow-up or uncertainty regarding the proportion of emergency operations, are indeed very real difficulties inherent in any study of this sort. We deal with these in the discussion, but nevertheless we believe that the study has produced new data despite these limitations. Dr Flum mentions that only recurrences requiring admission to hospital were included. One of the most important aspects of the study was that all patients were diagnosed according to the most objective criteria possible in clinical practice. Thus we defined acute diverticulitis (AD) by clinical and radiological criteria; recurrence as a new episode of AD was diagnosed according to the same definition and had to occur at least 2 months after complete resolution of the index episode. Patients with radiological evidence of acute diverticulitis were rarely treated as outpatients. Some patients treated with antibiotics for abdominal pain and fever in an outpatient setting without instrumental examination confirming the diagnosis of AD were simply classified as having persistence or recurrence of symptoms. It is of course the case that a multicentre study of diverticular disease as presented in our study is extremely difficult to carry out. Confounding factors include the accuracy of data recording, uniformity of adherence to the protocol, and variation in the clinical severity of the illness, length of follow-up and many other variables. Any future study will always be faced with the same practical difficulties to a greater or lesser extent. Despite these difficulties, we are, nevertheless, strongly of the view that the data presented represent an advance on previous studies. Admittedly, the results do not give a complete picture but they add to present knowledge beyond what was available before. G. A. Binda1, A. Serventi2 and D. F. Altomare3 1Department of General Surgery, Galliera Hospital, 16128 Genoa, 2Department of General Surgery, San Giacomo Hospital, 15067 Novi Ligure and 3Department of Emergency and Organ Transplantation, University of Bari, 70121 Bari, Italy (e-mail: gian.andrea.binda@galliera.it) DOI: 10.1002/bjs.8768

Sympathetic Ablation for PrimaryPalmar Hyperhidrosis: CouldControversies be solved?

Sympathetic Ablation for Primary Palmar Hyperhidrosis: Could Controversies be solved? Excessive perspiration of the palms of unknown etiology is present in a substantial number of the young people. It may cause severe social, emotional and occupational handicaps. A multitude of therapies exist, but sympathetic ablation is the only method that may obtain permanent relief. Sympathectomy, however, is not devoid of consequences, compensatory hyperhidrosis (increase in perspiration in areas of the body unaffected by the sympathetic ablation) is the most important and may attain devastating proportions. With the advent of thoracoscopic surgery, several modifications of the standard T2-T3 ablation were introduced. It was postulated that lowering the level of ablation and reducing its extent would attenuate the amount of compensatory hyperhidrosis..

Optimization of sympathectomy to treat palmar hyperhidrosis

To the Editor,We read with interest the article by Deng et al. [1] andcompliment them for the important review they performed.This review, which includes articles from the last decade,comes to a conclusion regarding the best level of sympa-thetic ablation for the treatment of primary palmar hyper-hidrosis shared by many authors (T3). However, in athorough review (246 references) on the subject comparingthe correlation of the method for sympathetic ablation withthe subsequent occurrence of compensatory sweating [2],the authors could not define any such correlation.In reviewing your study, we found that five articles forthe period 2000–2006 were not included. These articlesreport the ablation of single ganglia [3–7]. Were there othersimilar omissions for the years 2007–2010? We wouldappreciate the comment of the authors about these omis-sions. Would the inclusion of these series in their studypossibly change their conclusion?

Letter to the Editor: Percutaneous Chemical Dorsal ­Sympathectomy for Hyperhidrosis

Minim Invas Neurosurg 2011; 54: 290 A. E. P. Cameron 1 , C. Connery 2 , J. R. M. De Campos 3 , M. Hashmonai 4 , P. B. Licht 5 , C. H. Schick 6 , G. Bischof 7 , on behalf of the International Society of Symapathetic Surgery 1 Department of Surgery , The Ipswich Hospital , Ipswich , UK 2 Department of Surgery , St Luke’sRoosevelt Hospital Center , New York , NY , USA 3 Department of Thoracic Surgery , University of Sao Paolo , Sao Paolo , Brazil 4 Faculty of Medicine , Technion-Israel Institue of Technology , Haifa , Israel 5 Department of Cardiothoracic Surgery , Odense University Hospital , Odense , Denmark 6 German Hyperhidrosiscenter , Surgery Isar Clinic , Munich , Germany 7 Department of Surgery , St Josef Hospital , Surgery , Vienna , Austria