Christoph H. Schick

Radiofrequency Thermotherapy for Treating Axillary Hyperhidrosis.

BACKGROUND Thermotherapy has been established between conservative and surgical options as a minimally invasive method for the treatment of axillary hyperhidrosis. OBJECTIVE The objective of this study was to present radiofrequency thermotherapy (RFTT) as a safe and effective new treatment method. MATERIALS AND METHODS Thirty adult patients with pronounced axillary hyperhidrosis were treated with RFTT with noninsulated microneedles 3 times at intervals of 6 weeks. Subjective improvement was rated using the Hyperhidrosis Disease Severity Scale (HDSS) and Dermatology Life Quality Index (DLQI). Satisfaction and estimated reduction of sweating were monitored. Objective measurements were made using gravimetry. Adverse effects were recorded in follow-up. At the 6-month follow-up, improvement in sweating was seen in 27 patients. The HDSS dropped from 3.4 to 2.1, the DLQI improved significantly from 16 to 7. The gravimetric measurements of sweat were reduced from 221 to 33 mg/min. The average reduction of sweating was reported to be 72%. Adverse effects were generally mild and improved rapidly. CONCLUSION Radiofrequency thermotherapy was shown to be an effective and minimally invasive treatment option for axillary hyperhidrosis. Patients described their sweating as normal. The method clearly has the potential to normalize axillary sweating.

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.

Transumbilical thoracic sympathectomy with an ultrathin flexible endoscope in a series of 38 patients

We read with interest the article by Zhu et al. [1] that described a novel approach to thoracic sympathetic ablation. We also read their recently published online article on pigs, which presumably predated their experience on humans, a wise and correct approach [2]. Each surgical technique has its pros and cons. In the present case, there was only one skin wound, hiding within the umbilicus instead of two to four incisions on the thorax. Each pleural cavity had only one access wound instead of two in the standard thoracoscopic techniques. On the other hand, three access wound were created in the peritoneal cavity, two of them in the diaphragms. Furthermore, the technique described by Zhu et al. required an additional instrument not included in the standard endoscopic armamentarium. Each wound that penetrates a cavity may result in adhesions and also may damage internal organs. In the present method, not only the pleural cavities are violated, but the peritoneum as well. In view of all these remarks, we would appreciate their comment on the merits of their technique over the standard transthoracic approach. Pursuing the NOTES principle, transesophageal sympathectomy also has been performed [3]. These approaches are feasible. Are they desirable? Are they suitable for the general surgical practice? A further note of caution: the authors stated that the first rib was not visible in most of the cases. Did they apply a clip and perform a postoperative chest x-ray to confirm their count? Most authors claim that the first rib is usually visible during the procedure, mainly in its anterior part [4]. The majority of sympathectomies are performed by rib count and correct identification is of paramount importance.

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

Have robots a future in sympathetic operations

Fabre and colleagues [1] recently reported their experience of both lateral and circumferential tracheal repair with special reference to the already described use of cartilage-reinforced forearm free flaps [2]. Of 12 patients, 2 underwent lateral repair of esophagotracheal fistula, 4 salvage operations, and 6 tracheal/carinal replacement for adenoid cystic carcinoma (ACC) (n 1⁄4 5) or malacia (n 1⁄4 1). Although flap-wrapped aortic allografts have proved useful in elective central airway replacement [3], and recently in the emergency setting [4], Fabre and colleagues claim that “we believe this technique, with a mortality of about 50%, should not be used.” Therefore, we take the opportunity to briefly compare the patient data of their six tracheal/carinal replacements with the data from our study [3] (enrollment from 2005 to 2007) of 6 patients undergoing tracheal resection involving the carinal region in four cases, followed by repair with aortic allografts, for ACC (n 1⁄4 5) or mucoepidermoid tumor (n 1⁄4 1): (1) In-hospital mortality, 2/6 versus zero; (2) pathology (ACC patients), 4/5 R1 resection versus 5/5 R0 resection; (3) mean survival time, 25 months versus 64 months (of our 6 patients, 3 died at 26, 45, and 77 months, and the 3 survivors at 72, 76, and 87 months are currently in full-time employment). According to the 100% efficacy of chemoradiation in locally advanced ACC of the trachea reported by Allen and colleagues [5] and recently confirmed through electronic communication with the authors, we decided, however, not to include further patients in our study. The results of Fabre and colleagues reporting severe mortality and morbidity (mainly adult respiratory distress syndrome and arterial rupture), and poor quality of life (mucus plugging and 66% of definitive tracheostomy) after implantation of their neoconduit also pleads in favor of chemoradiation as an alternative therapy. By contrast, the successes obtained in esophagotracheal fistula operations demonstrate the relevance of fasciocutaneous flaps in the setting of lateral tracheal repair [1].

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