Primary hyperhidrosis is an idiopathic condition characterized by excessive sweating, particularly in response to temperature or emotional stimuli. This condition occurs in up to 1% of the population, with an apparent increased prevalence in the Far East.1 Commonly affected areas of the body are the palms, feet, axillae, and face. These symptoms usually begin in childhood or adolescence, often representing an incapacitating and embarrassing disorder that can interfere with social and professional activities.2 Medical treatments such as antiperspirants, aluminum chloride, tap water iontophoresis, oral anticholinergics, and botulinum toxin A injection, alleviate symptoms only transiently.
Early surgical management for hyperhidrosis required an open thoracotomy that required a prolonged recovery period and caused significant morbidity, including Horner syndrome.3,4 However, with recent advances in video-assisted thoracoscopy, upper thoracic dorsal sympathectomy has been shown as a safe and minimally invasive procedure for palmar and axillary hyperhidrosis.5 The procedure can be performed using single or multiple ports.6,7
Because of improvement in video-assisted thorascopy since the 1990s, the incidence and severity of complications following treatment have declined, with reported incidences of Horner syndrome ranging from 0 to 1.9%.8-11
This prospective study aimed to show operative and postoperative results after simultaneous bilateral video-assisted thorascopic sympathectomy using single versus multiple ports.
MATERIAL AND METHODS
The study enrolled 71 consecutive patients who underwent thorascopic sympathectomy for primary palmar hyperhidrosis at King Fahd Hospital between January 2008 and June 2012 (Table 1). All patients had experienced disabling palmar hyperhidrosis since adolescence and had undergone medical therapy with topical agents without much improvement. The patients reported that the symptoms had significantly affected their work or social life. All patients underwent a careful clinical history; basic preoperative investigations were performed including chest radiograph. A thorax CT is not routinely requested unless suggested by history, or an abnormal chest radiograph. Patients with secondary hyperhidrosis were excluded from this study.
Patients were consecutively randomized into two groups: group A (35 patients) underwent multiple ports video-assisted sympathectomy and group B (36 patients) underwent single-port video-assisted sympathectomy.
Informed consent was obtained before surgery and the study was approved by the hospital's ethics committee. Our protocol included monthly follow-ups for 1 year postoperative. Follow-up data were obtained in all patients by telephone interview. Clinical examination was added only when the patient reported objective physical signs, such as Horner syndrome.
Surgery was performed under general anesthesia with one-lung ventilation using a double-lumen endotracheal tube. Patients were placed in semi-Fowler position with arms gently abducted. A small roll was placed transversely behind the scapulae to slightly elevate the axillae from the operating table. A fingertip pulse oximeter probe was used to record the changing pattern of the plethysmographic curve on the operated side. The surgeon stood at the side, facing the patient, and the video screen was positioned above the patient's head.
In the multiple ports group, after exclusion of the lung, a 5-mm, 0 degree telescope and two additional 3-mm ports for micro instruments were used. The sympathetic chain is easily identified under the parietal pleura, running vertically over the necks of the ribs in the upper costovertebral region. The mediastinal pleura was opened and the sympathetic chain was dissected, severed, and removed from the second thoracic ganglion (T2) to the third (T3). Dissection was carried out with high-frequency cautery except at the level of T2, where no coagulation was used to prevent current diffusion to the stellate ganglion. Generally we continue the dissection by cauterizing/dividing the pleura for 5 cm lateral to the chain, including an aberrant nerve bundle of Kuntz if identified. The transected ends of the sympathetic chain are separated as far as possible and cauterized to prevent regrowth of the nerve and recurrence of symptoms. Care should be taken not to divide the sympathetic chain above the level of the second rib for the treatment of palmar hyperhidrosis because it increases the risk of Horner syndrome and contributes little benefit.
In the single-port group, after exclusion of the lung, a single, 1-cm-long incision was made for insertion of a 12-mm trocar into the pleural cavity at the third intercostal space in the midaxillary line. A straightforward, 0 degree operating thoracoscope was introduced. The dorsal sympathetic chain was identified running along the neck of the ribs close to the costovertebral junctions. The first rib was always identified by direct vision or, in patients with adiposity, by palpation under visual control. The stellate ganglion (T1) was avoided. A diathermy hook inserted through the thoracoscope was used to completely divide the sympathetic trunk over the neck of the second and third ribs (T2–T3) including the rami communicanti and the accessory fibers of Kuntz, if present. At this level, the chain was divided with diathermy cautery after gentle anterior traction on the nerve; hook recoil after division was avoided to prevent vascular or lung injury. In order to destroy all the accessory sympathetic fibers, we dissected the pleura along the second rib up to about 5 cm lateral to the sympathetic chain.
In both groups, the entire procedure was then repeated on the opposite side, without changing the position of the patient or the operative setting. Complete ablation of the ganglia was validated by the presence of peripheral vasodilatation, warm and dry hands, and an instant change in amplitude of the waveform patterns of the pulse oximeter, indicating an increase in circulation after sympathectomy. At the end of the procedure, a temporary 10-gauge chest tube was inserted into the thoracic cavity through the surgical incision and connected to a water-seal system applying a mild suction. After the patient's lung was reinflated, the chest tube was quickly removed and the incision was closed. A chest radiograph was performed during the first postoperative day before discharge to ascertain complete lung expansion. All patients received postoperative analgesics.
Patient demographic information was collected preoperatively. We evaluated the effect of two operative techniques on the following clinical outcomes:
- operative time, defined as the interval between first port incision and completion of wound closure
- intraoperative complications
- postoperative complications, including pneumothorax, hemothorax, Horner syndrome, recurrence, and compensatory sweating
- postoperative length of hospital stay, defined as the interval between date of intervention and date of hospital discharge
- perioperative mortality, defined as the percentage of patients who died of causes related or unrelated to disease or procedure within 30 days of surgery.
The data associated with the procedure were calculated and expressed as percentages and mean ± SD in different situations by using a paired t test. Differences were significant at P<0.05. All analysis was performed with the SPSS 13.0 for Windows.
Table 1 outlines patient demographics and operative and postoperative outcomes. The two groups were similar in terms of age and sex distribution.
Operative time was not statistically significant (P=0.19); mean operative time in group A was 39.03 minutes ± 5.1 minutes, compared with 37.07 minutes ± 7.1 minutes in group B. No intraoperative complications occurred, and no patient required conversion to an open procedure.
Postoperative length of hospital stay was not statistically significant (P=0.15); mean postoperative length of stay was 1.1 days ± 0.4 days in group A and 1.2 days ± 0.3 days in group B.
In both groups, the procedure success rate was 100%—no patient developed Horner syndrome and none died perioperatively. Residual minimal pneumothorax occurred in two patients (5.7%) in group A and in one patient (2.8%) in group B. Minimal hemothorax occurred in one patient (2.9%) in group A and in three patients (8.3%) in group B. In our patients, all pneumothoraces were small, limited, and resolved without chest tube placement. The hemothoraces were small and none needed drainage.
Compensatory hyperhidrosis affecting the trunk and/or abdomen occurred in seven patients (20%) in group A and eight (22.2%) in group B. The difference in the rate of compensatory hyperhidrosis in the two groups was not statistically significant and the symptoms were not severe enough to interfere with lifestyle, so required no further treatment.
Parenteral analgesia was not required and postoperative pain was managed effectively in both groups with oral analgesics alone. Follow-up of all patients at 1 year revealed no recurrence of symptoms and all patients maintained dry hands.
Thoracotomy was the standard surgical approach for hyperhidrosis but the introduction of video-assisted thoracoscopic surgery (VATS) and the advances in video-endoscopic technology have replaced open surgery for performing sympathectomy.12 As a result, patients have shorter hospital stays, reduced morbidity, less pain, and better cosmetic results.13
Video-assisted thoracoscopic sympathectomy usually is done through multiple ports but more recently, the integration of electrocautery/diathermy to the thoracoscope permits a single-port procedure. This single-port approach has been shown to be faster and provides excellent cosmetic and functional outcomes.14-16
The development of residual pneumothorax is a well-known complication of endoscopic thoracic procedures and is not specific to this procedure.7 In our patients, residual minimal pneumothorax occurred in two patients (5.7%) in group A and in one patient (2.8%) in group B, a rate comparable to that in other reports.14,17
No episodes of postoperative Horner syndrome were reported in this study. Interestingly, in the early reports of endoscopic thoracic surgery, the incidence of Horner syndrome was as high as 12%, but improved familiarity with the procedure and the anatomy (in particular the avoidance of the superior third of the stellate ganglion) has reduced incidence rates to less than 1%.18,19
Compensatory hyperhidrosis affecting the trunk and/or abdomen occurred in seven patients (20%) in group A and eight (22.2%) in group B. Other studies have reported compensatory hyperhidrosis between 67% and 85%.20-23 The incidence and degree of compensatory hyperhidrosis appear to depend on the extent of resection of the sympathetic chain, which may account for the differences in various studies. Our technique involves limited excision of the ganglia at T2-T3 for palmar hyperhidrosis to minimize compensatory symptoms. The symptoms were not severe enough to interfere with lifestyle, and this required no further treatment.
No recurrence was observed in our patients. These results are in line with those reported by other authors.18,24 Previous studies showed that overall intraoperative morbidity (for example, chylothorax, or lung or vessel damage) is nearly 0.2%, including in patients converted to open thoracotomy.9,24,25 However none of these issues were observed in our study.
No significant differences were found between bilateral multiple ports and single-port video-assisted thorascopic sympathectomies. Both are effective, safe, and minimally invasive procedures that permanently improve the quality of life in patients with palmar hyperhidrosis. Careful patient selection and preoperative counseling are important to ensure a satisfactory outcome.
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