Ivan Macia

Thoracic sympathicolysis for primary hyperhidrosis

BackgroundBilateral upper thoracic sympathectomy or sympathicolysis, currently the standard treatment for palmar or axillary hyperhidrosis, is regarded as a safe procedure. This study evaluates the quantitative and qualitative incidence of intraoperative and postoperative complications resulting from bilateral thoracic sympathicolysis.MethodsFrom 1996 to 2004, 458 consecutive patients with primary hyperhidrosis underwent surgery. These patients comprised 143 men (31.2%) and 315 women (68.7%) with a mean age of 26 years (range, 14–52 years). In all but seven cases, the procedure was bilaterally synchronous.ResultsNo mortality was recorded. The anhydrosis rate was 97.4%, with a hypohidrosis rate of 2.4% and a failure rate of 0.2%. The latter was resolved with reintervention. The mean hospital stay was 17 h. The rate of major perioperative complications with conversion to thoracotomy was 0.4%. The overall rate of postoperative complications was 3.6%. The complications and rates observed were as follows: pneumothorax (2.06%), subcutaneous emphysema (1.08%), pleural bleeding (0.2%), hemothorax (0.1%), and atelectasis (0.1%). Compensatory hyperhidrosis was observed in 48.4% of the patients, but the sensation of compensatory hyperhidrosis was reported in 85.6% of the cases. Excessive dryness of the hands was reported in 0.38%, Horner’s syndrome in 0.32%, and gustatory hyperhidrosis in 1.1% of the cases. The overall satisfaction rate was 88.5%.ConclusionsThe results suggest that endoscopic bilateral thoracic sympathicolysis is an effective method for managing primary hyperhidrosis, especially severe palmar hyperhidrosis, but it is necessary to inform patients fully concerning the undesirable effects.

Resultados de la simpaticólisis y la simpatectomía torácica superior bilateral endoscópica en el tratamiento de la hiperhidrosis primaria. Estudio de 1.016 procedimientos

Objetivo La simpaticolisis y la simpatectomia toracica son actualmente los tratamientos habituales de la hiperhidrosis primaria. En este estudio evaluamos la incidencia cuantitativa y cualitativa de las complicaciones peri y postoperatorias. Pacientes y metodos Desde 1996 a 2004 se intervino consecutivamente a 520 pacientes (364 mujeres) con hiperhidrosis primaria, con una edad media de 26,8 anos. En todos, excepto en 24 casos, el procedimiento fue bilateral. La intervencion se realizo en un tiempo en 484 pacientes (simpaticolisis) y en 2 tiempos en 36 (simpatectomia). Resultados No hubo mortalidad. La anhidrosis del territorio deseado fue del 97,6%, se aprecio hipohidrosis en el 2,2% y hubo un 0,2% de fallos que requirieron reintervencion. La estancia media fue de 72 h en el grupo de simpatectomia y de 17 h en el de simpaticolisis. Se registro un 0,2%de complicaciones intraoperatorias mayores con reconversion a toracotomia. Se produjo un 5,2% de complicaciones postoperatorias (un 22,5% en las simpatectomias y un 3,55% en la simpaticolisis), de las cuales el neumotorax fuela mas frecuente. Se observo hiperhidrosis compensadora en un 48,4% de los casos, sequedad excesiva de manos y ptosis palpebral en el 0,38%, e hiperhidrosis gustativa en un 0,9% de casos. El grado de satisfaccion fue muy elevado (88,5%) y solo un 2,3% de los pacientes se manifestaron muy insatisfechos. Conclusiones De los resultados obtenidos se deduce que tanto la simpaticolisis como la simpatectomia son tratamientos adecuados de la hiperhidrosis, si bien la mayor sencillez y menor agresividad de la primera nos llevan a considerarla el tratamiento de eleccion en la hiperhidrosis primaria.

Results of High Bilateral Endoscopic Thoracic Sympathectomy and Sympatholysis in the Treatment of Primary Hyperhidrosis: a Study of 1016 Procedures

OBJECTIVE Thoracic sympatholysis and sympathectomy are the current standard treatments for primary hyperhidrosis. In this study, we evaluated the incidence of peri- and postoperative complications associated with these procedures. PATIENTS AND METHODS From 1996 to 2004, 520 consecutive patients (364 women), with a mean age of 26.8 years, were treated for primary hyperhidrosis at our hospital. The procedure was bilateral in all but 24 cases. The 484 patients in the sympatholysis group underwent a single intervention while the 36 patients in the sympathectomy group underwent 2 separate interventions. RESULTS No deaths occurred. Anhidrosis of the target area was achieved in 97.6% of patients while 2.2% experienced hypohidrosis. In 0.2% of the cases, the procedure was initially unsuccessful and a second intervention was required. The mean duration of hospital stay was 72 hours for patients in the sympathectomy group and 17 hours for the sympatholysis group. Serious intraoperative complications requiring conversion to thoracotomy were recorded in 0.2% of patients. Postoperative complications--of which pneumothorax was the most common--occurred in 5.2% of the cases (in 22.5% of the sympathectomy group and 3.55% of the sympatholysis group). Compensatory hyperhidrosis occurred in 48.4% of the patients, excessive dryness of the hands and palpebral ptosis in 0.38%, and gustatory sweating in 0.9%. The degree of patient satisfaction was quite high (88.5%) and only 2.3% were very unsatisfied. CONCLUSIONS Given the results obtained, we can conclude that both sympatholysis and sympathectomy are appropriate treatments for hyperhidrosis. Nonetheless, because sympatholysis is both easier to perform and less aggressive, we consider it the treatment of choice for primary hyperhidrosis.

Elastofibroma Dorsi: An Uncommon and Under-Diagnosed Tumour

Abstract Elastofibroma dorsi is a relatively rare soft-tissue tumor located at the infra-scapular level and/or subscapular regions. It usually occurs between the fourth and seventh decade of life, and is more common in females. We reviewed sixteen elastofibromas diagnosed in 12 patients (7 females, 58.3%). Four patients had bilateral elastofibromas. The most common symptom was pain. Presumptive diagnosis was made by physical examination. Chest ultrasound, computed tomography and/or magnetic resonance imaging were performed to confirm the diagnosis. Surgery was performed under general anesthesia. No major complications were observed. Elastofibromas are tumors of the chest wall with an uncertain impact. Surgical resection is indicated only in symptomatic patients.

Fibroelastoma dorsi: un tumor infrecuente e infradiagnosticado

Elastofibroma dorsi is a relatively rare soft-tissue tumour localized at the infra-scapular level and/or subscapular regions. It usually occurs between the fourth and seventh decade of life, and is more common in females. We reviewed sixteen elastofibromas diagnosed in 12 patients (7 females, 58.3%). Four patients had bilateral elastofibromas. The most common symptom was pain. Presumptive diagnosis was made by physical examination. Chest ultrasound, computed tomography and/or magnetic resonance imaging were performed to confirm the diagnosis. Surgery was performed under general anaesthesia. No major complications were observed. Elastofibromas are tumours of the chest wall with an uncertain impact. Surgical resection is indicated only in symptomatic patients.

Quality study of a lung cancer committee: study of agreement between preoperative and pathological staging.

OBJECTIVE Accurate preoperative staging is essential to provide the best treatment for lung cancer. The objective of the present study was to determine agreement between preoperative and surgical-pathological staging and to analyse the impact of any disparity on treatment. METHODS This is a descriptive study of a series of 176 lung cancer cases treated by surgery between 2005 and 2007. Preoperative staging was based on clinical information and computed tomography (CT), positron emission tomography (PET), PET-CT, bronchoscopy and mediastinoscopy. In all cases, surgical-pathological staging was based on the analysis of surgical samples and the findings during surgery. Both preoperative and pathological stage determination were based on the TNM (tumour, node, metastasis) classification established in 1997. Concordance was measured by calculating agreement rates and the kappa value. RESULTS Preoperative and surgical-pathological staging agreed in 102 cases, an agreement rate of 58% and kappa value of 0.54 (95% confidence interval (CI) 0.44-0.63). The highest kappa value (0.68, 95% CI 0.53-0.82) was obtained in stage IA patients. Patients who underwent PET or PET-CT had a better kappa index (0.56, 95% CI 0.45-0.67, vs 0.39, 95% CI 0.21-0.56). Surgical-pathological staging validated surgery in 145 cases (82%), while 21 (12%) were revised to stage IIIA N2 and 10 (6%) to non-surgical stages. CONCLUSIONS Global agreement between preoperative and surgical-pathological staging was moderate. The best agreement was found in stages IV and IA.

An assessment of plantar hyperhidrosis after endoscopic thoracic sympathicolysis

BACKGROUND Endoscopic bilateral thoracic sympathicolysis (EBTS) is an effective and minimally invasive procedure used for patients with primary hyperhidrosis. The purpose of this study was to examine plantar hyperhidrosis before and after EBTS. METHODS A total of 198 patients with primary hyperhidrosis underwent 396 thoracoscopic sympathicolysis of ganglia T2-T3 in a prospective study. All completed a preoperative questionnaire, followed by a second questionnaire 12 months after the operation. The questionnaires evaluated sweating in the different body areas. Only the zones of anhydrosis were considered in delimiting the cutaneous expression of sympathetic ganglia T2-T3. RESULTS Redistribution of perspiration as reported by the patients comprised significant reductions in palmar and axillary hyperhidrosis, and an increase in the zone of the trunk and popliteal region. The incidence of plantar anhydrosis and plantar hypohidrosis was 30.3% and 20.7%, respectively (p < 0.001). CONCLUSIONS EBTS is followed by redistribution of body perspiration, with, and important, plantar anhydrosis and hypohidrosis. Although EBTS is the standard treatment for palmar primary hyperhidrosis, we must continue studying baseline sympathetic activity in patients affected by primary hyperhidrosis and the neuroanatomy of the sympathetic system to understand the redistribution of sweating and decrease of hyperhidrosis in the zones regulated by mental or emotional stimuli.

Localized (solitary) fibrous tumors of the pleura: an analysis of 15 patients.

BACKGROUND Localized fibrous tumors of the pleura (LFTPs) are rare neoplasms, which are considered to originate from submesothelial connective tissue. The aim of this article is to present 15 new cases because of their different clinical behaviors and to discuss the treatment of choice of such neoplasms. METHODS The records of 15 consecutive patients with LFTP operated at our Institution between 1995 and 2006 were retrospectively reviewed. Diagnostic procedures, clinical courses, and outcomes of these patients were studied. Total excision through a thoracotomy was performed in all patients. Neoplasms were considered to be malignant if one or more of the following histologic features were present: increasing mitotic activity; high cellularity with crowding and overlapping of nuclei; necrosis; and pleomorphism. RESULTS No operative mortality was reported. The mean follow-up time was 76 months. Malignant transformation was seen in 1 patient 26 months after resection of a benign tumor. Six cases were pathologically considered to be malignant: 2 patients developed local recurrence. One of these underwent redo-surgery and required pneumonectomy; in the other one surgery is not indicated because at the time of diagnosis the patient was 85 years. Currently, all patients are alive and 13 disease-free. CONCLUSIONS For histologically benign tumors, because of the risk of recurrence and malignant transformation, complete surgical resection is indicated and long-term follow-up is recommended in all patients. For malignant cases, complete surgical resection may be insufficient for the cure: further study should be performed to identify reliable prognostic factors to indicate and evaluate the effectiveness of systemic treatment.

Hiperhidrosis primaria. Situación actual de la cirugía del simpático

Primary hyperhidrosis-PH is an excessive sweating without known etiology. The PH is more frequent in women and in palms, soles and axillae. Medical treatment is not effective. The objective of the surgery is to remove or to disconnect sympathetic ganglia T2 (craniofacial PH or facial blushing), T3 (palmar PH) and T3-T4 (axillary PH). The surgical techniques are mainly resection/transection, ablation with electrocoagulation, sympathetic block by clipping and radiofrequency. Anhidrosis is achieved in 95% of the patients. The overall rate of complications is less than 5% and these are minor complications. The most important unwanted effect is reflex sweating, presented in 48% of the patients. Reflex sweating is more frequent in back, thorax and abdomen and it appears independently of the surgical technique. Ninety percent of the patients are very satisfied after surgery. Nowadays, thoracic sympathetic surgery is the gold standard for primary hyperhidrosis.

Intranodal thoracic schwannoma, an unusual type of neurogenic tumor

The primary intranodal schwannoma is an uncommon variant of schwannomas and extremely rare. We report the case of a 70-year-old woman who was found to have a soft tissue opacity in the right hemithorax on chest posteroanterior radiography and significant uptake of 18F-fluorodeoxyglucose on positron emission tomography. We performed thoracoscopic resection, and a definitive diagnosis of intranodal schwannoma was made from the pathological findings.