Paulo Kauffman

Quality of Life, Before and After Thoracic Sympathectomy: Report on 378 Operated Patients

BACKGROUND Thoracic sympathectomy is indicated to treat primary hyperhidrosis. The objective is to analyze the results and complications of thoracic sympathectomy and propose a questionnaire to assess the quality of life of patients. METHODS Between October 1995 and March 2002, 378 patients were evaluated. Sixty-two percent were female, with a mean age of 26.8 years old (range 9 to 70 years old). There were 57.4% patients with palmar-plantar hyperhidrosis; 25% with palmar, plantar, and axillary hyperhidrosis; 15.7% with pure axillary hyperhidrosis; and 6.5% with craniofacial hyperhidrosis. General anesthesia was used in 97.3%, epidural with sedation in 2.7%. The sympathetic chain was resected in 12.5%, thermal ablation with the electrical scalpel was performed in 66.3%, and with the harmonic scalpel in 21.2% of the patients. RESULTS Successful sympathectomies were performed in 90.3% of the patients; the follow-up was from 1 to 60 months (mean 12.4 +/- 8.3 months). The recurrence rates were 8.2% for palmar hyperhidrosis, 13.7% for pure axillary hyperhidrosis, 27.5% of which were reoperated successfully. Improvement of the plantar hyperhidrosis was also registered in 58%. Horners syndrome was reported in 1% with regression in half of them after 30 days. No mortality or serious complications were observed, nor the need to convert to thoracotomy. Of the total number of patients, 93.4% answered the quality of life questionnaire, 86.4% of whom noted improvement after the procedure. CONCLUSIONS Thoracic sympathectomy is a simple, effective, safe method for the treatment of hyperhidrosis, resulting in an improved quality of life for patients. The questionnaire documents this change.

The body mass index and level of resection: predictive factors for compensatory sweating after sympathectomy.

ObjectiveCompensatory sweating (CS) is the most common adverse event and the main cause of dissatisfaction among patients undergoing a VATS sympathectomy for the treatment of primary hyperhidrosis. It has been described that obese individuals experience more sweating than thinner ones. The aim of this study is to identify the Body Mass Index (BMI) and the level of resection as predictive factors for CS and its relation to levels of patient satisfaction following the procedure.MethodsFrom October 1998 to June 2003, 102 patients undergoing VATS sympathectomies (51 for palmar hyperhidrosis, PH, and 51 for axillary hyperhidrosis, AH) were prospectively surveyed. They were divided into three groups according to their BMI: Group I was composed of 19 patients with BMI<20 (9 patients with PH and 10 with AH); Group II was composed of 52 patients with 20 ≤BMI<25 (25 with PH and 27 with AH); and Group III was composed of 31 patients with BMI ≥ 25 (17 with PH and 14 with AH). Each procedure was simultaneously and bilaterally performed under general anesthesia using two 5.5mm trocars and a 30° optic system.ResultsPatients treated for PH (resection of T2-T3) had more severe CS than those with AH (resection of T3-T4) (p=0.007) and the greater the BMI, the greater the severity of the CS (p<0.001). No statistically significant difference was found between the BMI bands in relation to the degree of satisfaction (p=0.644), nor when we compared the degree of satisfaction to the degree of CS (p=0.316).ConclusionsThe greater the BMI, the more severe the CS, but this did not correlate with the patients’ level of satisfaction. Avoiding the resection of T2 sympathetic ganglia is also important in reducing the intensity of CS.

A randomized placebo-controlled trial of oxybutynin for the initial treatment of palmar and axillary hyperhidrosis

INTRODUCTION Video-assisted thoracic sympathectomy provides excellent resolution of palmar and axillary hyperhidrosis but is associated with compensatory hyperhidrosis. Low doses of oxybutynin, an anticholinergic medication that competitively antagonizes the muscarinic acetylcholine receptor, can be used to treat palmar hyperhidrosis with fewer side effects. OBJECTIVE This study evaluated the effectiveness and patient satisfaction of oral oxybutynin at low doses (5 mg twice daily) compared with placebo for treating palmar hyperhidrosis. METHODS This was prospective, randomized, and controlled study. From December 2010 to February 2011, 50 consecutive patients with palmar hyperhidrosis were treated with oxybutynin or placebo. Data were collected from 50 patients, but 5 (10.0%) were lost to follow-up. During the first week, patients received 2.5 mg of oxybutynin once daily in the evening. From days 8 to 21, they received 2.5 mg twice daily, and from day 22 to the end of week 6, they received 5 mg twice daily. All patients underwent two evaluations, before and after (6 weeks) the oxybutynin treatment, using a clinical questionnaire and a clinical protocol for quality of life. RESULTS Palmar and axillary hyperhidrosis improved in >70% of the patients, and 47.8% of those presented great improvement. Plantar hyperhidrosis improved in >90% of the patients. Most patients (65.2%) showed improvements in their quality of life. The side effects were minor, with dry mouth being the most frequent (47.8%). CONCLUSIONS Treatment of palmar and axillary hyperhidrosis with oxybutynin is a good initial alternative for treatment given that it presents good results and improves quality of life.

Twenty months of evolution following sympathectomy on patients with palmar hyperhidrosis: sympathectomy at the T3 level is better than at the T2 level.

OBJECTIVE To compare two surgical techniques (denervation levels) for sympathectomy using video-assisted thoracoscopy to treat palmar hyperhidrosis in the long-term. METHODS From May 2003 to June 2006, 60 patients with palmar hyperhidrosis were prospectively randomized for video-assisted thoracoscopic sympathectomy at the T2 or T3 ganglion level. They were followed for a mean of 20 months and were evaluated regarding their degree of improvement of palmar hyperhidrosis, incidence and severity of compensatory hyperhidrosis and its evolution over time, and quality of life. RESULTS Fifty-nine cases presented resolution of the palmar hyperhidrosis. One case of therapeutic failure occurred in the T3 group. Most of the patients presented an improvement in palmar hyperhidrosis, without any difference between the groups. Twenty months later, all patients in both groups presented some degree of compensatory hyperhidrosis but with less severity in the T3 group (p = 0.007). Compensatory hyperhidrosis developed in most patients during the first month after the operation, with incidence and severity that remained stable over time. An improvement in quality of life was seen starting from the first postoperative evaluation but without any difference between the groups. This improvement was maintained until the end of the follow-up. CONCLUSION Both techniques were effective for treating palmar hyperhidrosis. The most frequent complication was compensatory hyperhidrosis, which presented stable incidence and severity over the study period. Sympathectomy at the T3 level presented compensatory hyperhidrosis with less severity. Nevertheless, the improvement in quality of life was similar between the groups.

Objective evaluation of patients with palmar hyperhidrosis submitted to two levels of sympathectomy: T3 and T4

This study compares the results obtained of video-assisted sympathectomy performed on two distinct ganglion levels (third vs. fourth thoracic ganglion) in the treatment of palmar hyperhidrosis (PH), through a blind randomized clinical trial. All participants were randomized into two groups of 20 patients (G3 and G4) and underwent the operation, and were followed for 12 months. We used an objective method for measuring sweat, checking the transepidermal water loss (TEWL), and evaluated the quality-of-life (QoL) before and after the operation. All patients (n=40) ceased suffering from PH after surgery, with statistical difference when we compared the values of TEWL palmar preoperatively with their respective values at one week, one month, six months and 12 months. The main side effect observed was compensatory hyperhidrosis (CH), which was most frequent in G3 after 12 months of follow-up. There was an improvement in QoL since the first evaluation of the postoperative period with no difference between groups. Both techniques were effective in the treatment of PH, generating objective reduction of TEWL regardless of the ganglion operated. Sympathectomy G3 had a higher incidence of CH, yet the improvement in QoL was similar in both groups.

Diagnosis of limbs and neck arterial trauma using duplex ultrasonography

OBJECTIVE To evaluate duplex ultrasonography for diagnosis of arterial trauma in limbs and neck. METHOD Fifty-one wounds in 47 patients, with indication for arteriography, were prospectively studied and grouped according to the presence (PCS group: 21 wounds, 41.2%) or absence (ACS group: 30 wounds, 58.8%) of clinical signs of arterial injury. All underwent duplex ultrasonography and arteriography. RESULTS Arteriography disclosed arterial injury in 21 wounds, of which 19 were visualized by duplex ultrasonography. In the other 30 wounds neither methods disclosed any arterial injury. The sensitivity of duplex ultrasonography was 90.5%, the specificity was 100% and the accuracy was 96.1%. In PCS group duplex ultrasonography showed 14 injuries (93.3%) and one false-negative result, and in ACS group, five injuries (83.3%) and one false-negative result in the ACS group. CONCLUSIONS Duplex ultrasonography reproduces the results of arteriography as a non-invasive diagnostic method in trauma of the limbs and neck.

Evaluation of plantar hyperhidrosis in patients undergoing video-assisted thoracoscopic sympathectomy

BackgroundSympathectomy is the treatment of choice for primary hyperhidrosis. One curious occurrence that is difficult to explain from an anatomophysiological point of view in cases of video-assisted thoracoscopic sympathectomy (VATS) for the treatment of palmar hyperhidrosis (PH) is the observed improvement in plantar hyperhidrosis (PLH). Nevertheless, current reports on VATS rarely describe the effect on PLH or just give superficial data. The aim of this study was to prospectively investigate, how surgery affects PLH in patients with PH and PLH over one-year period.MethodsFrom May 2003 to January 2004, 70 consecutive patients with combined PH and PLH underwent VATS at the T2, T3, or T4 ganglion level (47 women and 23 men, with mean age of 23 years).ResultsImmediately after the operation, all the patients said they were free from PH episodes, except for two patients (2.8%) who suffered from continued PH. Compensatory hyperhidrosis (CH) of various degrees was observed in 58 (90.6%) patients after one year. Only 13 (20.3%) suffered from severe CH. There was a great initial improvement in PLH in 50% of the cases, followed by progressive regression, such that only 23.4% still presented that improvement after one year. The number of cases without overall improvement increased progressively (from 17.1% to 37.5%) and the numbers with slight improvement remained stable (32.9–39.1%). Of the 24 patients with no improvement after one year, 6 patients graded plantar sweating worse.ConclusionPatients with PH and PLH who undergo VATS to treat their PH present a good initial improvement in PLH that reduces to a lower level of improvement after the one-year period.

Is gender a predictive factor for satisfaction among patients undergoing sympathectomy to treat palmar hyperhidrosis

Video-assisted thoracic sympathectomy (VATS) is currently the procedure of choise for the definitive treatment of primary hyperhidrosis because it is an effective, safe, and minimally invasive method. The aim of VATS treatment is to improve the quality of life through the reduction of excessive sudoresis. The purpose of this study was to assess the quality of life after VATS for treating palmar hyperhidrosis according to gender. METHODS: A total of 1044 patients who submitted to the surgical treatment for palmar hyperhidrosis from June 2000 to February 2008 were retrospectively evaluated. The patients were divided into two groups according to gender [719 (68.8%) females and 325 (31.2%) males]. RESULTS: There are no statistically significant differences between genders with regard to the quality of life in palmar hyperhidrosis patients (p = 0.726). In the interview that was performed 30 days after surgery, the quality of life in the two groups had improved, with no statistical difference between the groups. CONCLUSION: Patients with palmar hyperhidrosis present with an improvement in the quality of life after VATS regardless of gender.

Evaluation of quality of life over time among 453 patients with hyperhidrosis submitted to endoscopic thoracic sympathectomy

OBJECTIVES Current data do not provide enough information on how quality of life (QoL) evolves over time in cases of endoscopic thoracic sympathectomy (ETS). The purpose of this study was to ascertain whether the immediate improvement in QoL after the surgery was sustained until the fifth postoperative year. METHODS This was a prospective, nonrandomized and uncontrolled study. From March 2001 to December 2003, 475 consecutive patients with hyperhidrosis submitted to ETS were included. A QoL questionnaire was applied at the preoperative day, around the 30th postoperative day, and after the fifth year. RESULTS After excluding 22 patients who did not answer all the questions, we analyzed 453 patients. Their ages ranged from 11 to 57 years old, with a mean of 25.3 + 7.9 years, including 297 female patients (65.6%). All patients were assessed on three occasions: before surgery, around the 30th postoperative day, and after the fifth postoperative year. The QoL before surgery was considered to be poor or very poor for all patients. The QoL around 30 days after surgery was better in 412 patients (90.9%), the same in 27 patients (6.0%), and worse in 14 patients (3.1%). After 5 years, 409 patients (90.3%) were better, 27 (6.0%) were the same, and 14 (3.1%) were worse. There were no differences between these postoperative times according to the McNemar statistical test. CONCLUSION The patients had an immediate improvement in QoL after ETS, and this improvement was sustained until the fifth postoperative year.

The Use of Oxybutynin for Treating Axillary Hyperhidrosis

BACKGROUND To evaluate the effectiveness and patient satisfaction with the use of oxybutynin for treating axillary hyperhidrosis in a large series of patients. METHODS One hundred two patients with axillary hyperhidrosis were treated with oxybutynin. During the first week, patients received 2.5 mg of oxybutynin once a day in the evening. From the 8th to the 42nd day, they received 2.5 mg twice a day, and from the 43rd day to the end of the 12th week, they received 5 mg twice a day. All of the patients underwent two evaluations: before and after (12 weeks) the oxybutynin treatment, using a clinical questionnaire; and a clinical protocol for quality of life (QOL). RESULTS More than 80% of the patients experienced an improvement in axillary hyperhidrosis; 36.3% of them presented a great improvement, and half of the patients showed improvements at all hyperhidrosis sites. Most of the patients showed improvements in the QOL (67.5%). The patients with very poor QOL before the treatment presented greater satisfaction levels after treatment. The side effects were minor, dry mouth being the most frequent (73.5%). CONCLUSIONS Oxybutynin is a good alternative to sympathectomy. It presents good results and improves QOL without the side effects of sympathectomy.