Sympathectomy for hyperhidrosis: should we place the clamps at T2–T3 or T3–T4?

Endoscopic thoracic sympathectomy is routinely used to treat severe hyperhidrosis. It is usually performed at the T2–T3 level of the nerve, but may produce less severe compensatory hidrosis if performed at a lower level. This study evaluates the outcome of 1,274 patients who underwent endoscopic thoracic sympathectomy for plamar, plantar, axillary or facial hyperhidrosis/blushing. Half of the patients were clamped at the T2–T3 level and half were clamped at the T3–T4 level. Postsurgical symptoms and side effects were assessed by interview. All of patients with palmar hyperhidrosis were cured or improved. Patients with plantar and axillary hyperhidrosis were more likely to be improved at T3–T4 level clamping. Patients with facial hyperhidrosis were more likely to be cured at T2–T3 level, but did show improvement at the T3–T4 level. Overall satisfaction was higher in the T3–T4 group. Some degree of mild compensatory sweating occurred in all patients. However, severe compensatory sweating was more common in the T2–T3 group. Around 2% of patients requested a reversal of their surgery. Endoscopic thoracic sympathectomy is a safe and effective treatment for hyperhidrosis. Clamping at the T3–T4 level has a more successful outcome. In particular, it appears to reduce the incidence of severe compensatory hidrosis.     

The body mass index and level of resection

OBJECTIVE: Compensatory 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. METHODS: From 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 < or =BMI<25 (25 with PH and 27 with AH); and Group III was composed of 31 patients with BMI > or =25 (17 with PH and 14 with AH). Each procedure was simultaneously and bilaterally performed under general anesthesia using two 5.5 mm trocars and a 30 degrees optic system. RESULTS: Patients 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). CONCLUSIONS: The 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.     

Upper thoracic sympathectomy for axillary osmidrosis or bromidrosis.

The difference between axillary osmidrosis (AO) and axillary bromidrosis (AB) is the degree of odor and quantity of sweat, which is associated with selection of therapeutic modality theoretically. Upper thoracic sympathectomy has been used for both diseases but its effect needs to be further evaluated with more clinical data. We collected 108 patients with AO or AB treated by upper thoracic sympathectomy from July 1995 to July 2002. Of these patients, 42 suffered AO alone, 17 had AB (AO with axillary hyperhidrosis [AH]), and 49 had AO with palmar hyperhidrosis (PH). Ninety-two patients (183 sides) received anterior subaxillary transthoracic endoscopic sympathectomy (TES) and 17 patients (33 sides) received posterior percutaneous thoracic phenol sympathicolysis (PTPS). The levels of sympathectomy or sympathicolysis were T3-4 for AO and AB, and T2-4 for AO with PH. Mean follow-up period was 45.2 months (13-97 months). The satisfaction rates of patients were 52.4%, 70.6% and 61.2% for AO, AB and AO with PH, respectively. The rates of patients with improvement and satisfaction were 78.6%, 88.2% and 85.7% for AO, AB, and AO with PH, respectively. These results suggest that upper thoracic sympathectomy may be an acceptable treatment for AB or AO with PH rather than AO only.     

Results, side effects and complications after thoracoscopic sympathetic block by clamping

Background Video-endoscopic sympathectomy is the current treatment of choice for severe primary hyperhidrosis. Because of the possible post-surgical side effects, the procedure is carried out using removable endoclips that block sympathetic nerve transmission. This study describes the short and “mid-term” side effects and complications of this method for the treatment of palmar, axillary, and facial hyperhidrosis. Materials and methods Two hundred and ninety-four sympathectomies were carried out between September 2003 and June 2006 and followed-up after 17 months. Patients with isolated facial hyperhidrosis were clamped at the T2–3 level clamping. Patients with isolated axillary hyperhidrosis were clamped at the T3–4 level. Results All patients with palmar and palmar-axillary hyperhidrosis were completely satisfied after clamping at the third thoracic ganglion (T3) level. Immediate complete recovery was achieved in 98% of patients post-surgery. Major complications were Horner’s syndrome (1%) and pneumothorax (3%). Compensatory sweating occurred in 22%. No cases of gustatory sweating were reported. All patients were “satisfied” with their results and no patients requested removal of the clips. Interpretation Thoracoscopic sympathecotomy clamping is a successful treatment for hyperhidrosis. Local hyperhydrosis does not reoccur after 17 months, but there is some degree of compensatory hyperhidrosis.     

CT引导下经皮穿刺射频热凝治疗原发性头、手多汗症的疗效分析

目的探讨CT引导下经皮穿刺射频热凝治疗原发性头、手多汗症的疗效及并发症。方法对宁波市康复医院疼痛科自2017年6月至2019年5月收治的30例原发性头、手多汗症患者予CT引导下经皮穿刺T3或T4交感神经链射频热凝治疗,并随访12个月以评估患者疗效及总结并发症发生情况。结果术后24例患者的多汗症状明显改善,总体满意率为80%。术中5例患者出现胸腔、肺部穿刺损伤,其中4例为气胸、1例为血胸;术后7例患者出现胸背、腋下或上臂疼痛麻木,10例患者出现胸背代偿性多汗,2例患者出现胸背及双侧足部代偿性多汗。结论CT引导下经皮穿刺射频热凝治疗原发性头、手多汗症有着长期的治疗效果及相对较低的并发症。     

Transthoracic endoscopic T-2, 3 sympathectomy for facial hyperhidrosis.

Twenty-five patients (20 men and 5 women) with the chief complaint of facial hyperhidrosis were treated by transthoracic endoscopic T-2, 3 sympathectomy. All patients were essentially in good health except the embarrassment of facial sweating. Fifteen of them also suffered from distressing palmar hyperhidrosis. The ages ranged from 18 to 40 years (mean age 25 years). All of them except two obtained a satisfactory improvement of facial hyperhidrosis after 3 months to 2 years of follow-up. One man demonstrated very mild ptosis in the right eye. Pre- and postoperative sympathetic skin response (SSR) revealed the absence rate from 20% to 72% with electrical stimulation (p < 0.05). This study shows that T-2, 3 sympathectomy is a choice of treatment for facial hyperhidrosis and sympathetic supply to the face may at least partly be from T-2, 3 level.     

Palmar and axillary hyperhidrosis treated with botulinum toxin: one-year clinical follow-up

Focal hyperhidrosis is a common and sometimes handicapping condition for which the presently most effective treatment, sympathectomy, often leads to irreversible side-effects. We aimed to study effectiveness and tolerability of an alternative treatment with botulinum toxin injections over a period of one year for this condition. Twenty-eight patients with palmar (n = 19) and/or axillary (n = 13) hyperhidrosis were treated with intracutaneous injections of botulinum toxin (Botox(R)) 2 U/4 cm2. Sweat function was studied clinically and by objective measurements after treatment of one side. Treated and untreated sides, and pre- and post-treatment skin areas were compared. Subjective evaluation was performed after treatment of one side and 2-5 months after treatment of both sides. Duration of effect was controlled by a one-year follow-up. Sweating disappeared in eight out of 13 patients with axillary and in five out of 19 with palmar hyperhidrosis, and was reduced markedly in another five out of 13 and 10 out of 19 patients. Two-thirds of those treated for hand sweat noticed a slight and transient reduction of power of finger grip. No side-effects were noticed after treatment of axillary hyperhidrosis. We find intracutaneous injections of botulinum toxin with this technique safe and effective, and due to the relatively long duration of effect the treatment should be recommended before sympathectomy for focal hyperhidrosis.     

Botulinum toxin-A therapy for palmar and plantar hyperhidrosis

In an open study regarding focal hyperhidrosis, we injected 45-65 mouse units of botulinum toxin A (Btx-A) per palm and 100 per sole intracutaneously to 28 hands and 6 feet. We observed patients for up to 10 months to evaluate the efficacy and tolerability of Btx-A for palmar and plantar hyperhidrosis. The mean sweat production significantly declined for both palmar and plantar hyperhidrosis quantitatively on the first month of therapy (P < 0.01). One patient had transient muscle weakness and mild thenar atrophy interfering with her daily activities for 10 days. Injections were otherwise tolerated well by the patients. In this trial Btx-A injection is found to be an effective and safe method of treatment for palmar and plantar hyperhidrosis.     

Autonomic function following endoscopic thoracic sympathotomy for hyperhidrosis

Purpose  

Primary palmar–plantar hyperhidrosis is the condition of excessive sweating of the hands and feet. For severe and medically refractory cases, endoscopic thoracic sympathotomy (ETS) is a bilateral ganglion-sparing disconnection between the stellate and T2 ganglion in an effort to minimize compensatory hyperhidrosis. The purpose of this study was to determine the effect of ETS on cardiac autonomic function.     

Botulinum A toxin improves life quality in severe primary focal hyperhidrosis

Focal hyperhidrosis is a condition that may disturb emotional, social and professional life. Treatment options for severe cases are surgical sympathectomy and local chemical sweat gland denervation by intradermal injections of botulinum toxin A (Btx A). The Dermatology Life Quality Index (DLQI) is a simple validated questionnaire designed to measure and compare disability in different skin diseases. The aim of this study was to assess quality of life with the DLQI before and after treatment with botulinum toxin injections in a group of patients with severe hyperhidrosis. DLQI was administered to 58 randomly chosen patients before and after treatment. All patients answered the DLQI questionnaire prior to treatment and 53/58 at mean 5.2 months after treatment. The mean DLQI score in the 58 patients before treatment was 10.3 (2-23). In the group of 16/53 patients who had a relapse of sweating when answering the DLQI a second time, no significant improvement was seen [score 10.6 before and 8.8 after treatment (P = 0.21)]. In patients without relapse, a 76% improvement was obtained (DLQI was reduced from 9.9 to 2.4; P < 0.0001). The study showed that focal hyperhidrosis may considerably reduce life quality and the disability experienced by the patients can be largely reversed by botulinum toxin injections.     

Endoscopic extraperitoneal lumbar sympathectomy for plantar hyperhidrosis: case report

A right sided endoscopic retroperitoneal lumbar sympathectomy was performed on a 23 year old female who had plantar hyperhidrosis. After the operation, the right foot temperature increased and the plantar hyperhidrosis was relieved. During the follow up period, both feet were warm and dry, although only the right side lumbar sympathectomy had been performed. The outcome appeared to be compatible with that of an open procedure but with minimal invasiveness.     

胸腔镜下单孔胸交感神经链切断术治疗原发性手汗症

目的探讨电视胸腔镜下单孔胸交感神经链切断术治疗原发性手汗症的疗效和安全性。方法 2009年4月至2011年12月,80例原发性手汗症患者在胸腔镜下单孔操作,分别行T2～T5不同节段交感神经链切断术,术中持续监测双手掌温以判断手术疗效,随访症状缓解情况、有无复发以及代偿性出汗情况。结果全组病例手术均获成功,平均手术时间为(49.8±4.2)min,术后患者手掌多汗症状消失,双手转为干燥温暖状,双手掌皮肤温度均较术前显著升高(P<0.05),无严重并发症发生。77例患者随访1～32月,平均16.8月。1例单手手汗复发,已再次手术治愈。发生代偿性多汗38例(47.5%),其中中度出汗2例,轻度出汗36例。行单纯T3、T4或联合T3+T4胸交感神经链切断者代偿性多汗发生率为42.6%(29/68);余节段切断者代偿性多汗发生率为75.0%(9/12)。结论胸腔镜下单孔胸交感神经链切断术治疗手汗症具有操作简单、安全有效、创伤小等特点,值得临床推广。     

PALMAR HYPERHIDROSIS

Fourteen men and 22 women, with an average age of 23 years (range 14–36 years), were operated on for hyperhidrosis of the upper extremity during the period from 1955 to 1970. Twenty-eight had had symptoms for more than 10 years. Resection of the 2nd and 3rd thoracic ganglia and the connecting sympathetic chain was carried out using a posterior approach; in 33 cases the operation was bilateral, and in three unilateral. Thirty-five patients were followed up after an average of 7.8 years (range 2–17 years). In one patient unilateral reoperation was carried out four months after the first operation. Since the first operation 34 patients had suffered from neither palmar nor axillary sweating. However, 20 had permanent compensatory hyperhidrosis, and 15 suffered from gustatory facial sweating, which had usually started within six months of operation. Four, in whom two spinal thoracic nerves had also been resected, reported marked dysaesthesia over the front of the chest and in the axilla, lasting for several years.     

Abolition of sympathetic skin responses following endoscopic thoracic sympathectomy

The recording of sympathetic skin responses (SSRs) is a simple, electrophysiological method to assess sympathetic nerve function. Within the last 10 years, SSRs have mainly been applied to delineate peripheral and central nervous system diseases, although the sympathetic nature of these responses was not fully documented, e.g., by a study of sympathectomy. We therefore recorded SSRs before and after 30 cases of endoscopic thoracic sympathectomy. The main indication was palmar hyperhidrosis, in which we found two types of SSR abnormalities. Most patients exhibited normal SSR waveforms but with increased amplitudes. The other patients exhibited abnormal SSRs which did not occur as single responses but as several consecutive waves. Thoracic sympathectomy always led to significant clinical improvement and to the abolition of ipsilateral palmar SSRs, demonstrating the sympathetic origin of these responses. We suggest that the assessment of sympathetic nerve activity by SSR recordings may be useful in sympathectomy. © 1996 John Wiley & Sons, Inc.     

Post-traumatic unilateral plantar hyperhidrosis

Localized unilateral hyperhidrosis is rare and poorly understood, sometimes stemming from trauma. Feet, quite vulnerable to trauma are affected by disease-mediated plantar hyperhidrosis, usually bilaterally. This report describes partial hyperhidrosis developing post-traumatically on the left plantar region of a 52-year-old male.     

高选择性脊神经后根切断术治疗痉挛性脑瘫

目的探讨应用高选择性脊神经后根切断术(SPR)治疗痉挛性脑瘫的疗效。方法对58例接受SPR治疗的痉挛性脑瘫患者,进行术后8~40个月的随访,并对其术后痉挛情况、交叉腿、尖足情况、肌力、感觉等情况进行评估。结果 14例肌张力Ⅳ级的患者术后平均肌张力降为1.71级,32例肌张力Ⅲ级的患者术后平均肌张力降为1.56级,12例肌张力Ⅱ级的患者术后平均肌张力降为1.16级。30例剪刀步态完全消失(51.72%),19例明显改善(32.76%),仍有9例改善不明显(15.51%)。合并尖足者共31例,术后足跟着地者27例。术后随访能独立行走者29例(50%),需搀扶者18例(31.03%),不能行走者11例(18.97%)。结论 SPR对解除痉挛、降低肌张力等方面是安全可靠、作用持久的,配合必要的康复训练,可明显改善肢体活动功能,提高生活质量。     

Further results of a 6-week period of treatment of neuroses in a therapeutic community

Comparison of results referring to 1971-74 in 630 patients with those from 1976-82 in 1,211 patients confirmed that according to the evaluation of therapists the immediate substantial symptomatic improvement still varies near 60%. In the evaluation of insight and changes in attitudes and behaviour a for obscure reason decline was recorder. The evaluation of the symptomatic effect by patients one year after terminated treatment increased from 42 to 49%. Comparison of the immediate evaluation by therapists with the immediate evaluation by patients revealed that therapists had a slight tendency to overestimate symptomatic improvement while patients constantly and considerably overestimate the therapeutic results in the sphere of insight and changes of attitudes and behaviour. Comparison of the immediate effect with a one-year follow-up, using rating scales filled in by the patients, confirmed a satisfactory stability of the effect. Approximately half the patients improved substantially one year after treatment.     

Risk reduction of long-term major adverse cardiovascular events after endoscopic thoracic sympathectomy in palmar hyperhidrosis

Purpose

Palmar hyperhidrosis (PH) is excessive sweating of the palms resulting from sympathetic overactivity, and patients who undergo endoscopic thoracic sympathectomy (ETS) show reduced cardiac demand after 1 year and improved cerebral perfusion within 2–4 weeks. However, the long-term risks of major adverse cardiovascular events (MACE) following ETS remain unclear.

Methods

We searched the Longitudinal National Health Insurance Database in Taiwan and identified PH patients (International Classification of Disease, Ninth Revision, Clinical Modification diagnostic code 708.8) from the outpatient database and patients who underwent ETS (procedure code 05.29) from the inpatient database between 2000 and 2010; furthermore, we excluded patients younger than 18 years of age or older than 65 years of age. We defined MACE as stroke (diagnostic codes 430–437), myocardial infarction (diagnostic code 410), or death. Patients followed until the first cardiac event or December 31, 2010. Risk factors were identified using a multivariable Cox proportional hazards regression.

Results

The incidence of MACE was significantly lower in patients with ETS (0.76%) than without (1.67%). In PH patients, ETS significantly reduced the risk of MACE (adjusted hazard ratio 0.473; 95% confidence interval 0.277–0.808).

Conclusion

PH patients who underwent ETS showed a reduced risk of MACE over a long-term follow-up period. This result could provide support for patients with PH who are considering undergoing ETS because of its additional cardiovascular benefits.

     

外伤性癫痫危险因素分析

目的 调查颅脑创伤(TBI)患者外伤性癫痫(PTE)的发生率、发作类型、危险因素及其认知功能等.方法 对我院脑系科中心2004年9月至2007年9月之间好转出院的TBI病例进行回顾性调查和电话随访及回访.纳入资料完整及能随访的患者共2023例.结果 (1)2 023例TBI患者中有98例出现PTE,其发生率为4.84%,高发年龄段为51～70岁和10岁以下.65例(66.32%)患者的PTE发生于外伤后1年以内;(2)TBI病情重、高龄、皮层损伤、蛛网膜下腔出血、多次手术治疗及受伤早期痫性发作均可增加PTE的发病率;(3)PTE 患者认知障碍和性格发生变化的发生率高于非PTE患者(P＜0.05).结论 癫痫发生与TBI严重程度、受伤年龄、损伤部位、影像学表现、治疗方法和伤后临床表现等有关.

Abstract：

Objective The purpose of this study was to investigate the incidence of posttraumatic seizure and epilepsy,the seizure type of epilepsy,risk factors of epilepsy and Recognition function.Methods The TBI cases discharged after the improvement from September 2004 to Septemher 2007 were retrospectively investigated and visited by telephone and 2023 cases was brought into study.Results (1)98 cases suffered PTE and the incidence of PTE was 4.84%;the age of high incidence was 51～70 years old and less than 10 years old. 65 cases(66.32%)occurred in less than one year after trauma.(2)Serious injury,old age,cortical injury,subarachnoid hemorrhage,many surgical treatment and early epileptic seizure after injury would increase the incidence of PTE(P＜0.05).(3)The incidence of cognitive impairment was higher in patients with PTE than non-PTE patients(P＜0.05).Conclusion The risk of posttranmatic seizure and epilepsy is correlation with the severity of TBI,age,injury location,imaging findings,treatment methods and clinical manifestations after injury.