Moshe Hashmonai

Thoracoscopic sympathectomy for palmar hyperhidrosis: Ablate or resect?

BackgroundUpper thoracoscopic sympathectomy, obtained either by ablation or resection of the appropriate ganglia, is now the preferred treatment for primary palmar hyperhidrosis. Therefore, we undertook a review to compare the relative efficacy of these two techniques.MethodsA Medline search was performed for the years 1974–99 to identify all published studies of thoracoscopic sympathectomy for hyperhidrosis.ResultsIn all, 33 studies were identified and divided into two groups—ablation and resection. When the resection method was used, the immediate success rate was 99.76%, whereas the ablation method achieved dry hands in 95.2% of cases (p=0.00001). Palmar sweating recurred in 0% of patients treated via resection and 0–4.4% treated with ablation. Ptosis was noted in 0.92% of cases after ablation and in 1.72% after resection (p=0.017).ConclusionsResection yields superior results, yet the majority of surgeons ablate, probably because it is easier, requires a shorter operating time, leads to fewer cases of Horner’s syndrome, and because resympathectomy eventually overcomes initial failure.

The treatment of primary palmar hyperhidrosis: A review

Primary palmar hyperhidrosis (HH) is a pathological condition of overperspiration caused by excessive secretion of the eccrine sweat glands, the etiology of which is unknown. This disorder affects a small but significant proportion of the young population all over the world. Neither systemic nor topical drugs have been found to satisfactorily alleviate the symptoms. Although the topical injection of botulinum has recently been reported to reduce the amount of local perspiration, long-term results are required before a definitive evaluation of this method can be made. Hypnosis, psychotherapy, and biofeedback have been beneficial in a limited-number of cases. While radiation achieves atrophy of the sweat glands, its detrimental effects prohibit its use. Iontophoresis has attained some satisfactory results but it has not been assessed long term. Percutaneous computed tomography-guided phenol sympathicolysis achieves excellent immediate results, but its long-term failure rate is prohibitive. Furthermore, percutaneous radiofrequency sympathicolysis may be an effective procedure, but its long-term results are not superior to surgical sympathectomy. On the other hand, surgical upper dorsal (T2-T3) sympathectomy achieves excellent long-term results and the thoracoscopic approach has supplanted the open procedures. Despite some sequelae, mainly in the form of neuralgia and compensatory sweating which cannot be predicted and may be distressing, surgical sympathectomy remains the best treatment for palmar hyperhidrosis.

Postoperative Suction Drainage of the Axilla: for How Long? Prospective Randomised Trial

OBJECTIVE To define the correct time to remove the drain after axillary dissection for carcinoma of the breast. DESIGN Prospective randomised trial. SETTING Two public hospitals, Israel. SUBJECTS 90 women who required axillary dissection for carcinoma of the breast. INTERVENTIONS 42 were randomised to have the drain removed on postoperative day 3, and 48 to keep the drain in until discharge had decreased to less than 35 ml/24 hours. MAIN OUTCOME MEASURES Formation of seromas or wound infections, need to reinsert the drain, and duration of hospital stay. RESULTS Early removal of the axillary drain was associated with a significantly higher incidence of seromas (9/42 compared with 2/48, p = 0.02) unless the total amount of fluid drained during the first three postoperative days was less than 250 ml. CONCLUSION Drains should be removed after axillary dissection only when the daily amount of fluid discharged is low, unless the drainage during the first three days is less than 250 ml.

Upper dorsal thoracoscopic sympathectomy for palmar hyperhidrosis: improved intermediate-term results.

PURPOSE The purpose of this study was to examine the immediate and mid-term results of thoracoscopic upper dorsal (T2-T3) sympathectomy for primary palmar hyperhidrosis. METHODS From June 1993 to October 1994 we performed 106 sympathectomies on 53 patients with palmar hyperhidrosis. Thirty-four female patients and 19 male patients ranging in age from 15 to 44 years, (mean 23.1 years) were studied. Both sides were operated during the same surgical procedure. The T2-T3 ganglia were resected by electrocuting with a hook and were removed for histologic examination. Follow-up for a mean of 19.25 months was obtained on 52 patients (104 operated limbs). RESULTS All limbs were completely dry at the end of the procedure, and hyperhidrosis did not recur during the whole follow-up period. Short-term postoperative complications (mainly atelectasis, pneumonia, pneumothorax, and hemothorax) occurred in six (11.3%) patients. Long-term sequelae were observed in 43 (81.1%) patients and included Horners syndrome (9 patients, 17.3%, one side only in each patient), neuralgia (7 patients, 13.5%), and compensatory hyperhidrosis (35 patients, 67.3%). These sequelae were not permanent in all cases, and the degree of severity was variable. Six (11.5%) patients, three of whom regretted being operated, were dissatisfied with their results: one because of Horners syndrome, one because of persisting neuralgia, and four because of compensatory sweating. CONCLUSIONS Despite the large number of postoperative long-term sequelae, 88.5% of patients expressed subjective satisfaction from the procedure. Obtaining 100% of dry hands on mid-term follow-up makes this approach rewarding.

The Correlation Between the Method of Sympathetic Ablation for Palmar Hyperhidrosis and the Occurrence of Compensatory Hyperhidrosis: A Review

BackgroundUpper dorsal sympathectomy achieves excellent long-term results in the treatment of primary palmar hyperhidrosis. Compensatory hyperhidrosis (CHH) remains an unexplained sequel of this treatment, attaining in a small percentage of cases disastrous proportions. It has been claimed that lowering the level of sympathectomy (from T2 to T3 and even T4), substituting resection by other means of ablation, and limiting its extend reduce the occurrence of this sequel. This review was designed to evaluate the validity of these claims.MethodsA MEDLINE search was performed for the years 1990–2006 and all publications about thoracoscopic upper dorsal sympathectomy for hyperhidrosis were retrieved.ResultsThe search identified 42 techniques of sympathetic ablation. However, pertinent data for the present study were reported for only 23 techniques with multiple publications found only for 10. The only statistically valid results from this review point that T2 resection and R2 transection of the chain (over the second rib) ensue in less CHH than does electrocoagulation of T2. Further comparisons were probably prevented due to the enormous disparity in the reported results, indicating lack of standardization in definitions.ConclusionsThe compiled results published so far in the literature do not support the claims that lowering the level of sympathetic ablation, using a method of ablation other than resection, or restricting the extend of sympathetic ablation for primary palmar hyperhidrosis result in less CHH. In the future, standardization of the methods of retrieving and reporting data are necessary to allow such a comparison of data.

Subclavian artery occlusion after radiotherapy for carcinoma of the breast.

Disturbance of the arterial circulation in the ipsilateral upper limb following mastectomy is a rare sequel attributed to adjuvant radiotherapy. A review of the literature revealed 20 such cases, and two more are presented. Different mechanisms of injury leading to arterial occlusion have been proposed. This is a late complication with a considerable time lag between irradiation and onset of symptoms. The symptoms vary in type and severity, but are consistent with peripheral occlusive arterial disease. To alleviate symptoms and prevent limb loss, reconstructive vascular surgery is advocated, and was successfully performed in one of our patients.

History of sympathetic surgery

Abstract.The first reported operation on the upper sympathetic system was performed by Alexander in 1889. The initial indications (epilepsy, exophthalmic goiter, idiocy, glaucoma) are obsolete. For some subsequent indications (angina pectoris, vasospastic disorders, and painful conditions) sympathectomy has still a limited application. The main indications today are hyperhidrosis (since 1920) and blushing. Renewed attempts to perform the operation for psychological conditions have been reported. The technique of sympathectomy has been modified over the century, with a trend to minimize the extent of surgery: from open to endoscopic approaches; from resection of ganglia to thermoablation, thermotransection, and clipping. The sequelae of the operation (mainly compensatory hyperhidrosis) present a major problem in a small percentage of operated patients. Techniques of reversal (by nerve grafting and unclipping) have been proposed. Meticulous follow-up studies are required to evaluate the merits of these techniques. Improved knowledge of the functions and interrelations of the autonomic nervous system is required to understand the mechanism of these sequelae and learn how to avoid or treat them.

Emergency Minilaparotomy Cholecystectomy for Acute Cholecystitis: Prospective Randomized Trial—Implications for the Laparoscopic Era

Abstract. This prospective controlled trial evaluates the efficacy of minicholecystectomy (MC) in cases of acute cholecystitis compared to that of conventional cholecystectomy (CC) and discusses its implications in the laparoscopic era. Sixty consecutive patients with acute cholecystitis were prospectively randomized into two groups: MC group (30 cases) and CC group (30 cases). The two groups were well matched with regard to age, sex, weight/height index, previous upper abdominal surgery, and APACHE II scores. The mean length of incision was 5.5 cm (range 4.5–9.0 cm) in the MC group compared to 13.5 cm (range 12–16 cm) in the CC group. No significant differences were found between MC and CC with regard to operative time (69.1 ± 17.0 and 68.1 ± 15.4 minutes, respectively;p= 0.82), operative difficulty on a 1 to 10 scale (5.2 ± 1.5 versus 4.6 ± 1.6, respectively; p= 0.177), and complication rate (11% and 17%, respectively; p= 0.19). Significantly lower analgesia requirements were noted in the MC group: 27.5 ± 14.6 mg of morphine sulfate compared to 44.5 ± 13.2 mg in the CC group (p < 0.001). In addition, the duration of hospital stay was significantly shorter for MC patients (3.1 ± 1.0 days) than in CC patients (4.7 ± 1.2 days) (p < 0.001). Twenty-two patients (73.3%) in the MC group were reported to return to normal daily activities 2 weeks after the operation, compared to only 12 (40%) in the CC group (p= 0.0028). MC is safe and applicable as an emergency procedure for acute cholecystitis. It is superior to CC in terms of convalescence and cosmesis. The results of MC in the setting of acute cholecystitis compare favorably with the published results of laparoscopic cholecystectomy.

Highly aggressive behaviour of occult papillary thyroid carcinoma

Occult papillary thyroid carcinoma is generally associated with an excellent prognosis. Distant metastasis of this tumour is extremely rare. A case of occult papillary thyroid carcinoma with metastases to the lungs, cervical lymph nodes, skeleton, and the brain is reported. The tumour expressed itself in extremely aggressive clinical behaviour and responded only partially to aggressive therapy. The controversial methods of treatment for occult papillary thyroid carcinoma are also discussed.

Carcinoid tumor of the common bile duct.

A case of a primary carcinoid tumor of the common bile duct is presented. Diagnostic and therapeutic uncertainties of this extremely rare cause of jaundice are discussed.