Christer Drott

Endoscopic transthoracic sympathectomy: An efficient and safe method for the treatment of hyperhidrosis

BACKGROUND Hyperhidrosis of the palms, axillae, and face has a strong negative impact on the quality of life for many persons. Existing nonsurgical therapeutic options are far from ideal. Definitive cure can be obtained by upper thoracic sympathectomy. The traditional open surgical technique is a major procedure; few patients and doctors have found that risk-benefit considerations favor surgery. Endoscopic minimal invasive surgical techniques are now available. OBJECTIVE We investigated whether endoscopic ablation of the upper thoracic sympathetic chain is efficient and safe in the treatment of hyperhidrosis. METHODS We treated 850 patients with bilateral endoscopic transthoracic sympathectomy. RESULTS There was no mortality or life-threatening complication. Nine patients (1%) required intercostal drainage because of hemothorax or pneumothorax. Treatment failure occurred in 18 cases (2%) and symptoms recurred in 17 patients (2%). At the end of follow-up (median, 31 months) 98% of the patients reported satisfactory results. CONCLUSION Endoscopic transthoracic sympathectomy is an efficient, safe, and minimally invasive surgical method for the treatment of palmar, axillary, and facial hyperhidrosis.

The borås experience of endoscopic thoracic sympathicotomy for palmar, axillary, facial hyperhidrosis and facial blushing

OBJECTIVE To study the outcome of endoscopic thoracic sympaticotomy (ETS) for palmar, axillary, facial hyperhidrosis and facial blushing. SUBJECTS 1152 patients, 59% women and 41% men. INTERVENTION ETS was performed by transection of the sympathetic chain where it overlies the second and third rib. The nerve was divided also over the fourth rib in patients with axillary hyperhidrosis. Questionnaires were sent to all patients. MAIN OUTCOME MEASURES The effect of surgery was assessed by a 10 grad visual analogue scale (VAS) by the patients. The results were divided into effect rate (the effect on the symptom) and overall satisfaction rate, taking into account any side effects and complications apart from the effect. RESULTS The response rate was 90%. The mean follow up time, effect rate and overall satisfaction rate were: 38 months for palmar hyperhidrosis, 99.4% and 87%; 26 months for axillary hyperhidrosis, 94.5% and 68%; 31 months for facial hyperhidrosis, 97% and 76%; 8 months for facial blushing, 96% and 85%. CONCLUSION ETS is a very effective procedure in palmar, axillary and facial hyperhidrosis and facial blushing. The overall satisfaction rate is very good for palmar hyperhidrosis and facial blushing, not equally good but acceptable for facial hyperhidrosis. The lower satisfaction rate in patients with axillary hyperhidrosis makes this a questionable indication for ETS.

Endoscopic electrocautery of the thoracic sympathetic chain. A minimally invasive way to treat palmar hyperhidrosis.

Four hundred and fifty patients with palmar hyperhidrosis have undergone endoscopic thoracic sympathetic electrocautery since 1987 in our department. The procedure requires only minor modifications of standard laparoscopic and urological equipment. The median operating time for a bilateral procedure was 31 minutes (15-120), hospital stay was 1 day postoperatively (1-8), and patients returned to work within 4 (1-40) days. Complications in the whole material were few and mild, pneumothorax (n = 2), haemothorax (n = 1), and Horners syndrome (n = 1). Five patients required reoperation (four because of primary failure to destroy the nerve and one for recurrent symptoms). The first consecutive 130 of these patients have been followed up by a questionnaire. At follow-up (median 196 days after operation, range 35-1419) all patients but three, who are awaiting reoperation were satisfied with the result. The discomfort and side effects of the operation were in most cases mild and short. This technique makes it possible to widen the indications for operation for people with palmar hyperhidrosis.

Thoracoscopy for autonomic disorders

Sympathetic denervation of the arm, the hand, and the heart may now be performed using minimal thoracoscopic procedures. During a 5-year period more than 500 patients were operated on with no major and only a few minor complications. An operation time of 25 minutes, a hospital stay of 1 day, and sick leave of less than 1 week have made the operation suitable for autonomous disorders such as hyperhidrosis. Other conditions such as causalgia, vascular insufficiency, and angina pectoris may be improved or disappear after sympathectomy, but the recurrence rate in Raynauds disease is high.

Secondary aortoenteric fistulas--an analysis of 42 cases.

Secondary aortoenteric fistulas are seen with an increasing frequency which parallels the expansion of reconstructive vascular surgery. During a 12-year period 42 cases have been collected from the hospitals, which perform most of the vascular surgery in Sweden (0.7% of vascular operations). Twenty-five were seen after operation for aortic aneurysm, 15 for aortoiliac occlusive disease, one after renal artery ligation (as a part of reconstruction for renovascular hypertension) and one after operation for an iliac pseudoaneurysm. The frequency of complications during and after the primary operation was high. The interval between operation and onset of fistula symptoms was significantly shorter if there had been infectious complications, the median interval was 32 months, the longest being 10 years. The most important symptom was gastrointestinal haemorrhage, consisting of several small bleeds often combined with septic complications. A large number of negative investigations usually preceded the final diagnosis which was made at exploratory laparotomy. After surgery for the fistula the frequency of complications and mortality, were very high. Mortality was 58%, the most common cause of death being a blow out of the aortic stump. Of those leaving hospital, several further operations were performed with a high mortality. Recurrence of the fistula occurred in 16 out of 34 patients who survived surgery. At follow-up (12-74 months after fistula closure) seven patients were still alive.

Facial blushing treated by sympathetic denervation – longlasting benefits in 831 patients

Background  Severe facial blushing may have a strong negative impact on the quality of life and is one of the cardinal symptoms of social phobia. If traditional therapeutic options such as psychotherapy and pharmacological treatment fail, interruption of the sympathetic innervation to the face offers good results, however long‐term results may not be good.

Long-term effect of endoscopic transthoracic sympathicotomy on heart rate variability and QT dispersion in severe angina pectoris.

UNLABELLED We evaluated short and long-term effects on QT dispersion and autonomic balance after endoscopic transthoracic sympathicotomy (ETS). Heart rate variability (HRV) reflects autonomic balance of the heart. QT dispersion is a marker of cardiac electrical instability in patients with ischemic heart disease. Holter recordings for 24 h and a twelve-lead ECG were made prior to, 1 month, 1 year and 2 years after ETS. HRV was analysed in time domain and spectral analysis was performed during controlled respiration in supine position and during head up tilt. Dispersion of QT time and QTc were calculated. Of 88 patients, 62 (60) were eligible for HRV (QT-dispersion) analysis after 1 month, 39 (38) patients after 1 year and 23 (24) patients after 2 years. The HRV analysis showed a significant change of indices reflecting sympatho-vagal balance indicating significantly reduced sympathetic (LF) and increased vagal (HF, rMSSD) tone. These changes still persisted after 2 years. Global HRV increased over time with significant elevation of SDANN after 2 years. QT dispersion was significantly reduced 1 month after surgery and the dispersion was further diminished 2 years later. CONCLUSION ETS changed HRV and QT dispersion which could imply reduced risk for malignant arrhythmias and death after ETS.

Vasomotor and sudomotor function in the hand after thoracoscopic transection of the sympathetic chain: implications for choice of therapeutic strategy.

The degree of sympatholysis achieved by thoracoscopic transection of the sympathetic chain (sympathicotomy) was evaluated by measuring sudo‐ and vasomotor function in the hands before and after surgery in 12 patients with palmar hyperhidrosis. Our results show a marked reduction in sweat production and a cutaneous vasodilatation which remained unchanged during the 6 months follow‐up, whereas sudo‐ and vasomotor reflexes normalized within this time. Skin temperature variations did not correlate to skin perfusion changes. Since all subjects reported dry and warm hands throughout the follow‐up period, our results indicate that recording reflex responses to sympathoexcitatory stimuli does not adequately reflect clinical outcome of subtotal sympatholytic procedures performed for hyperhidrosis. Monitoring of clinical outcome should therefore include measurement of baseline sweat production and skin perfusion. However, the normalized reflex responses highlight the incomplete sympatholysis achieved by thoracoscopic sympathicotomy, which may be beneficial in some pathological conditions (such as hyperhidrosis) but detrimental in others.

Effect of Endoscopic Transthoracic Sympathicotomy on Heart Rate Variability in Severe Angina Pectoris

Endoscopic transthoracic sympathicotomy (ETS) is a recently developed technique to divide sympathetic nerves. ETS has been shown to improve symptoms and reduce ischemia in patients with severe angina pectoris. Low heart rate variability (HRV) in patients with ischemic heart disease carries an adverse prognosis. HRV reflects autonomic response of the heart and a shift in the sympathovagal balance towards parasympathetic dominance could be a marker of improved prognosis. HRV might also be used as an indicator of surgical success in sympathetic heart denervation. Heart rate was recorded in 57 patients before and after ETS. Registration was recorded during controlled respiration in the supine position and at tilt test over 10 minutes and spectral analysis was performed. Twenty-four hour Holter recordings were analyzed in the time domain. During the controlled setting, the high-frequency (HF) component (0.15 to 0.40 Hz) increased significantly whereas the low-frequency (LF) component (0.04 to 0.15 Hz) did not change significantly. The LF/HF ratio at tilt test was reduced from 1.3 to 0.8 (p <0.01). The time-domain analysis showed a significant increase of the mean RR interval (923 to 1,006 ms, p <0.001) and indexes reflecting parasympathetic tone also increased significantly (the root-mean square of difference measured from 24.3 to 29.5 ms, p <0.001 and the proportion of adjacent RR intervals >50% measured from 5.5% to 8.2%, p <0.01), whereas measurements reflecting global HRV did not change. In addition to relief of symptoms and reduced ischemia in severe angina pectoris, ETS caused a shift of sympathovagal balance toward parasympathetic tone. This might explain the anti-ischemic effect and have prognostic implications.

Endoscopic thoracic sympathectomy … and no regrets. Reply to Dr Drummond

Editor – Over the past 10 years, endoscopic thoracic sympathectomy (ETS) has been put forward as an effective treatment for facial blushing. In several series of patients, including one published recently in this journal, 1 self-reported ratings of blushing decreased substantially after surgery and only a low incidence of adverse outcomes was encountered. 2–4 Although the operation is usually successful in the short term, side-effects from the procedure may ultimately cause patient dissatisfaction (Reisfeld, http://www.sweaty-palms.com/ blushing.html). Unfortunately, the distress experienced by a minority of patients after surgical sympathectomy is given little weight in most of the published literature. Nevertheless, the establishment of support groups and Internet forums testify that this distress is real and is not limited to a few isolated cases (e.g. http://home.swipnet.se/sympatiska/index3.htm; http:// www.ets-sideeffects.netfirms.com; http://pub157.ezboard.com/ betsandreversals). In fact, dissatisfaction with the long-term outcome after ETS has resulted in the development of a nerve graft procedure to reverse the sympathectomy in the hope that this would also eliminate disabling side-effects. 5,6 In anticipation of unwanted side-effects, some surgeons prefer to clamp rather than sever the sympathetic chain to facilitate later reversal of the procedure. 4 The most common reason for dissatisfaction with ETS is the development of excessive (‘compensatory’) sweating below the level of the sympathectomy. 3,7–10 Compensatory sweating develops in up to 90% of patients who undergo surgical sympathectomy of the upper limbs and face, and can be severe and disabling. 10 Although not as widely recognized as compensatory sweating, some patients also develop gustatory sweating and a range of other less specific symptoms after ETS. 3,4 Bilateral thoracic sympathectomy alters cardiovascular control and inhibits increases in cardiac output during exercise. 11,12 Whether this contributes to the circulatory problems and chronic fatigue reported by some sympathectomized patients is unclear. From a psychological point of view, it is hard to endorse a destructive surgical procedure to prevent the physiological disturbances associated with anxiety, 13 particularly when the procedure carries risks of operative complications and disabling side-effects. In the case of emotional blushing, perceptions about blushing frequently do not match physiological signs. In particular, people who are concerned about blushing consistently report high levels of social distress and overestimate the intensity of blushing when they feel self-conscious or embarrassed. 14 That is, the patient’s problem often is fear of blushing rather than blushing itself. This fear develops easily; simply telling people who usually are unconcerned about blushing that they blushed during a social encounter can engender embarrassment and concern about blushing in future social encounters. 15 Drott et al . 1 noted that ‘patients should be encouraged to try non-surgical options as the first line of treatment’ for facial blushing (page 118). In my view ETS should not be offered to people concerned about recurrent emotional blushing, because the risks of irreversible operative complications and side-effects outweigh the potential for indirect and possibly transient psychological gains.