Differens options in thoracoscopic

sympathectomy

Hans Pilegaard, Ass. Prof, MD

Department of Cardiothoracic SurgeryAarhus University Hospital, Skejby

Denmark

13th Turkish Thoracic Society CongressIstanbul Turkey

Hyperhidrosis

Strutton et al. J Am Acad Dermatol 2004; 51:241-248

National questionnaire 150.000 householdsUS prevalence 2.8%

7.8 millions individuals

4 millions axillarwork

emotionalpsychologicalsocial

Hyperhidrosis

• Blushing• Facial• Palmar• Axillary• Foot

• Raynaud syndrome• Cardiac arrhytmia?• Angina pectoris?

Thoracoscopic treatment

Topical

Aluminium chloride (AlCl3-6H2O)

Anticholinergic agentsAstringent agents (Glutaraldehyde, formalin)IontophoresisBotulinum toxin

Excision of glands in the axillary regionLiposuctionLaser treatment

Thoracotomy Kotzareff 1920 Kotzareff A. Rev Med Suisse Romande 1920; 40:111-

113

Supraclavicular approach Telford 1935Telford E. Br J Surg 1935; 23:448-450

Anterior approach Polumbo 1956Polumbo LT. Arch Surg 1956;72:659-66

Transaxillary Goets & Marr 1944Goets R, Marr J. Clinical Proceedings 1944; 3:102-114

Posterior Adson 1929Cloward 1969Cloward. J Neurosurgery 1969; 30:545-551

Axillar extrapleural Roos 1971Roos D. Ann Surg 1971; 173:429-442

Open sympathectomy

Thoracoscopy Hughes 1942Hughes J. Proc Royal Soc Med 1942; 35:585-586

Thoracoscopy Goets & Marr 1944Goets R, Marr J. Clinical Proceedings 1944; 3:102-

114

Thoracoscopy Kux 1946-54Kux E. Georg Thieme Verlag, Stuttgart 1954

VATS 1980´s -

Thoracoscopic sympathectomy

Thoracoscopic sympathectomy

EasyFast (minuttes)Good visualizationSmall incisions

OutpatientAwakeLocal anaestesia

Elia et al. Awake one stage bilateral thoracoscopic sympathectomy for palmar hyperhidrosis: A safe outpatient procedure. 2nd EACTS/ESTS joint meeting, Leipzig, Germany 2004

Definitions

• Sympathotomy– Transection

• Sympathectomy– Resection– Ablation

Thoracoscopy

• Needle, 5mm, 10mm

• Uniportal• 2 ports• 3 ports can be necessary

Methods

• Electrocoagulation• Harmonic scalpel• Laser• Clipping

– Reversal

Electric vs harmonic scalpel

• Non randomized prospective• N=1515 patients• 24 hours, 7 days and 30 days• Responserate: 90%/68%/27%• No difference either by method or

level

de Campos JR et al. ICVTS: in press JR

Clipping

• N=727 patients – responsrate 92%• T2: 399, T2+3: 55, T3+4: 273• 34 patients have had clip removed• T2: 21, T2+3: 7, T3+4: 6 • 15 patients. decrease in

compensatory sweating

Sugimura H et al. J Thor Cardiovasc Surg 2009;137(6): 1370-8

Supine Single lumen tube

Harmonic scalpelTwo ports

Method

Reverse Trendelenburg

Blushing Th 2

Palmar Th 2-3 Axillary Th 2-3-4

Sympathectomy level

Sympathicotomy - left

Facial blushing and hyperhidrosis

T1-T2-T3 Drott et al. Br j Dermatol 1998;138:639-43.

T2 Kim et al. Eur J Cardiothor Surg 2004;26:396-400

Doolabh et al. Ann Thor Surg 2004;77:410-4Dewey et al. Ann Thor Surg 2006;81:1227-33Chou et al. Surg Endoscpo 2006;20:1749-53Licht et al. Ann Thor Surg 2006;81:1863-6Weksler et al. Thorac Surg Clin 2008;18:183-191

T2-T3 Drott et al. J Cosmet Dermatol 2000;1:115-9

Licht et al. Ann Thor Surg 2006;81:1863-6

Facial blushing and hyperhidrosis

• Follow-up questionaire – 2 centers• N=189 • Responsrate 96%• Outcome similar• Compensatory sweating• T2 83% - T2-3 95% p=0.02

Licht et al. Ann Thor Surg 2006;81:1863-6

Facial blushing

• RCT• T2 vs T2-T3• Study size n=200• N= 55• No difference

+200 papers

Most recommend T2-T3

Palmar hyperhidrosis

Chiou TS & Chen SC. Br J Surg 1999; 86:45-47Reisfeld R et al. Surg Laparosc Endosc Percutan Tech 2002; 12:255-267Kao MC. Ann Thorac Surg 2001; 72:667-668Andrews & Rennie JA. Br J Surg 1997; 84:1702-1704Lin CC. Surg Endosc 1990; 4:224-226

T2

Dumont P et al. Ann Thorac Surg 2005; 78:1801-1807 Zacherl J et al. Ann Thorac Surg 1999; 68:1177-1181 Gossot D et al. Ann Thorac Surg 2003; 75:1075-1079

Yilmaz EN et al. Eur J Cardiothorac Surg 1996; 10:168-172Lardinois D & Ris HB. Eur J Cardiothorac Surg 2002; 21:67-70Nicholson ML et al. Ann R Coll Surg Engl 1994; 76:311-314

T2-T4

T2-T5

T2 vs T3Palmar hyperhidrosis

• N= 60 patients• Succesrate: 59/60• Compensatory hyperhidrosis

– No differens in number, but in severity

– T2/T3: 13/4 p= 0.007

Yazbek G et al: Clinics 2009;64(8):743-9Yazbe

T3 vs T2-T4Palmar hyperhidrosis

• N= 232 patients

Compensatorysweating

T2-4N=115

T3N=117

p

N= 33 25

Mild 15 12

Moderate 7 9

Severe 11 4 < 0.05

Xu Li et al. Ann Thor Surg 2008;85:1747-52

Axillary hyperhidrosis

T2-T4 Zacherl J al. Ann Thorac Surg 1999; 68:1177-1181Hsu CP et al. Arch Surg 2001; 136:1115-1117Dumont P et al. Ann Thorac Surg 2005; 78:1801-1807 Rex LO et al. Eur J Surg Suppl 1998;23-26 Drott C & Claes G. Cardiovasc Surg 1996; 4:788-790 Ahn SS et al. Ann Vasc Surg 2000; 14:415-420

T2-T3 Fox AD et al. Eur J Vasc Endovasc Surg 1999; 17:343-346Andrews BT & Rennie JA. Br J Surg 1997; 84:1702-1704Kao MC et al. Ann Acad Med Singapore 1996; 25:673-678

T2 Chiou TS & Chen SC. Br J Surg 1999; 86:45-47

T4 vs T3-4Axillary hyperhidrosis

• N= 64 patients• RCT

Compensatory sweating

T3-4 T3 p T3-4 T3 P

Mild 16 14 18 13

Moderate

11 2 < 0.001

11 1 < 0.001

6 mdr 12 mdr

Munia MAS et al. Clinics 2008;63(6);771-4

Compensatory sweating

• N=158 patients• Responsrate 89%

– T2 facial blushing and hyperhidrosis– T2-3 palmar hyperhidrosis– T2-4 axillary hyperhidrosis

Level of sympathectomy

Severe sweating %

T2 21

T2-3 36

T2-4 49

Licht et al. Ann Thor Surg 2004;78:427-31

P=0.04

Gustatory sweating

• N=238 patients• Responsrate 96%• Gustatory sweating 32%

Level of sympathectomy

Gustatory sweating %

T2 27

T2-3 29

T2-4 44

Licht et al. Ann Thor Surg 2006;81:1043-7

P=0.04

Information to the patient

• Succes rate• Sideeffects

– Compensatory sweating– Gustatoric sweating– Horner’s syndrome– Heart rate

• Definitiv operation• Telarenta T. Eur J Surg Suppl 1998;580:17-8

Succesrate

• Facial blushing and hyperhidrosis 90%

• Palmar hyperhidrosis100%

• Axillary hyperhidrosis 80%

Sideeffects

• Compensatory sweating 90%• Gustatoric sweating 35%• Horner’s syndrome > 1%• Heart rate at rest 10%

• Dry hands

• Return to basic not a possibility

Side effect - Harlequin

Eur J Cardiothor Surg 2010;37:959

• 1997-2007• N=669• 48 reoperation

Number

Improved

Unilateral 29 96%

Bilateral 6 50%

recurrence 13 75%80% compensatory sweating38% worsening

Licht et al. Ann thor Surg 2010;89:1087-90

Conclusion

T2 for facial blushing and hyperhidrosis

T3 for palmar hyperhidrosis

T4 for axillary hyperhidrosis

Conclusion

Most patients are satisfied with the operation

90% of the patients will get compensatory sweating

Signifikant compensatory sweatingis more frequent after

T2-4 sympathectomi for axillary hyperhidrosis

Good information before the operationis mandatory

Conclusion