Endoscopic transthoracic limited sympathotomy for palmar-plantar hyperhidrosis: outcomes and complications during a 10-year period

Abstract

Objective: To review surgical results of endoscopic transthoracic limited sympathotomy for palmar-plantar hyperhidrosis during the past decade.

Patients and methods: We retrospectively reviewed 155 consecutive patients who underwent surgery from June 30, 2000, through December 31, 2009, for medically refractory palmar-plantar hyperhidrosis using a technique of T1-T2 sympathotomy disconnection, designed for successful palmar response and minimization of complications.

Results: Of the 155 patients, 44 (28.4%) were male, and 111 (71.6%) were female; operative times averaged 38 minutes. No patient experienced Horner syndrome, intercostal neuralgia, or pneumothorax. The only surgical complication was hemothorax in 2 patients (1.3%); in 1 patient, it occurred immediately postoperatively and in the other patient, 10 days postoperatively; treatment in both patients was successful. All 155 patients had successful (warm and dry) palmar responses at discharge. Long-term follow-up (>3 months; mean, 40.2 months) was obtained for 148 patients (95.5%) with the following responses to surgery: 96.6% of patients experienced successful control of palmar sweating; 69.2% of patients experienced decreased axillary sweating; and 39.8% of patients experienced decreased plantar sweating. At follow-up, 5 patients had palmar sweating (3 patients, <3 months; 1 patient, 10-12 months; 1 patient, 16-18 months). Compensatory hyperhidrosis did not occur in 47 patients (31.7%); it was mild in 92 patients (62.2%), moderate in 7 patients (4.7%), and severe in 2 patients (1.3%).

Conclusion: In this series, a small-diameter uniportal approach has eliminated intercostal neuralgia. Selecting a T1-T2 sympathotomy yields an excellent palmar response, with a very low severe compensatory hyperhidrosis complication rate. The low failure rate was noted during 18 months of follow-up and suggests that longer follow-up is necessary in these patients.

FIGURE 1.

Left, Hollow trochar with obturator (first object) for perforating chest wall allows penetration of the chest wall through a small (<1 cm) incision, removal of the inner obturator, and passage of the Gaab straight lens endoscope with engineered attached monopolar cautery probe (second object). Pencil and tape measure provide perspectives of size. The Mayo engineered hollow trochar with blunt perforating obturator removed mates perfectly with the engineered endoscope/cautery unit. Right: upper, Position of patient at surgery; lower, Single small incision and uniportal access with endoscope and cautery combined.

FIGURE 2.

Left, Schematic drawing of sympathectomy vs sympathotomy. Note that sympathectomy, with use of ganglionectomy by definition, must sever the primary axon from the neuron in the intermediolateral cell column of the spinal cord (red) before primary or collateral synapse in the T2 ganglion. This injures the neurons at this level of the spinal cord, some of which may die, and may predispose the patient to spinal cord neuronal synaptic reorganization and severe compensatory hyperhidrosis. Sympathotomy interrupts only axons after potential T2 ganglion synapses, a less injurious effect on the neuron, and is the least destructive procedure possible for successful treatment of palmar hyperhidrosis. StG = stellate ganglion. Right, All sympathetic connections across the second rib between the StG and the T2 ganglion are severed. (A) depicts a single trunk, (b) multiple trunks (6 patients), (C) trunk with lateral nerves of Kuntz (16 patients). Severing all sympathetic innervation across the second rib between the StG and T2 ganglion ensures that only the StG can provide sympathetic outflow to the hand through the brachial plexus, and this strategy minimizes axonal injury at the spinal cord level (left panel).

FIGURE 3.

Two ways of assessing palmar hyperhidrosis. Upper, ventilated capsule measurements capture the detailed synchronous pulsatile and localized palmar (a and b traces) sweat output with emotional stimuli. Lt = left; rH = relative humidity; Rt = right. Lower, In same patient, the resting sweat produces a purple discoloration of the alizarin red indicator powder in palms but not the forearm. Lettered ovals refer to capsule locations.

FIGURE 4.

Linear relationship between mean measured relative humidity (rH) and normalized sweat rate. Top left, ventilated capsule setup for recording quantitative palmar and left (L) forearm sweat rates. Inset: A, The HIH 3610 (humidity sensor; Honeywell Sensing and Control, Golden valley, MN); b, thermistor probe to measure skin temperature; and C, desiccated air tubing connecting to capsule. All 3 capsule sites are plotted. Clustering of responses below 10% rH relates to low sweat rates in the forearm site. Lower left, Quantitative sweat output in patients studied before and after upper thoracic endoscopic sympathotomy. Mann-Whitney u test reveals highly significant reductions in sweat rate for both palms and less robust reduction in forearm. Preop = preoperatively; Postop = postoperatively. Lower right, Surprising palmar and forearm emotional sweat outburst in patient postop. Marked reduction in resting sweat was noted postop with serial 7 and naming states stimuli (from 0-5 minutes); however, when examiner touched patient's feet (7.5-10 minutes), a remarkable sweating response was noted in palms and L forearm postop. R = right. Upper right, Mild emotional-induced sweating is often detected postop but is usually unnoticed by the patient.

FIGURE 5.

Kaplan-Meier estimated survival free of surgical failure in 155 patients. Five of these patients had documented surgical failure, all within 2 years postoperatively. The median length of follow-up after surgery in the remaining 150 patients was 2.1 years; range, 1 day to 9.9 years. CI = confidence interval.