Abstract

Immediate and short-term results of endoscopic thoracic sympathectomy (ETS) for primary hyperhidrosis are good. Adverse effects have been identified clearly and are supposed to decrease with time. In this institutional report, the long-term results of ETS with regard to efficacy, side effects and patient satisfaction are presented. Fifteen patients were included and mean follow-up time was 12±2 years. ETS success rate, rate of compensatory sweating and degree of patient satisfaction were assessed. We detected 8 patients (53%) complaining about a decent to moderate recurrence of hand sweating and compensatory and gustatory sweating were observed in 9 (60%) and 5 (33%) patients, respectively. Reported side effects related to surgery were paresthesias of the upper limb and the thoracic wall in 8 patients (53%) and recurrent pain in the axillary region in one. At an average 12 years after surgery, 47% of patients were satisfied with the treatment results, 40% were disappointed. Six patients (40%) affirmed they would ask for the operation if it were to be redone. Our findings indicate that results of ETS deteriorate and compensatory sweating does not improve with time. It is mandatory to inform patients of the potential long-term adverse effects before surgery.

1. Introduction

Thoracoscopic sympathicotomy has emerged as the most effective and durable treatment for patients suffering from moderate to severe hyperhidrosis [1–3]. However, while short-term results and postoperative complications have been reported extensively in the literature, long-term follow-ups analysing the progression of the effected treatment and its excited side effects for five years and more are rare.

Compensatory sweating (CS) represents the most common side effect of sympathetic surgery and exerts a potential negative impact on patients' postoperative quality of life [4,5]. The relationship of CS to the extent and levels of sympathicotomy has been the subject of recent intense debate among thoracic surgeons [6]. The dilemma is, that symptom relief and the incidence of postoperative CS seem to be mutually dependent. Future refinements of surgical techniques should take into consideration both the potential for clinically significant CS as well as the potential for loss of treatment efficacy. Here, patient satisfaction is of overriding importance. Therefore, we surveyed in this retrospective single-centre study the 10-year postoperative course of patients to identify treatment efficiency and side effects and to determine patient satisfaction.

2. Materials and methods

2.1. Operative technique

Selective bilateral sympathicotomy was performed in a two-stage procedure. General anaesthesia using single-lung ventilation technique was applied in all patients. Patients were positioned in a lateral position. Two single 10- and 7-mm thoracoscopic ports, situated in the third and in the sixth intercostal space in the posterior axillary line were used. All patients underwent selective sympathicotomy by division of their sympathetic chain using a 30° videothoracoscope (Olympus, Hamburg, Germany) and electrocautery. The mediastinal pleura was opened and the sympathetic chain was identified. Its main trunk was mobilised and preserved. The Rami communicantes were divided at the levels T2 and T3 for palmar hyperhidrosis and T3 and T4 for isolated axillary hyperhidrosis. The combined symptoms of palmar and axillary hyperhidrosis were treated with dissection at levels T2 through T4. In addition, 5 cm parietal pleura over the adjacent rib was transversally cut from the sympathetic trunk to coagulate accessory fibres and Kuntz's nerve. Temperature probes were placed at the palm of each hand to monitor shifting of palmar perfusion. A 28-Fr chest tube was inserted into the chest during closure. The contralateral side was operated on the following day.

2.2. Data collection

Data of all patients undergoing thoracoscopic sympathicotomy from 1992 through 1997 at Schillerhoehe Hospital were retrospectively reviewed. Approval and individual consent was waived by the Institutional Review Board of the Eberhard Karls University Tübingen. All patients underwent routine office follow-up at 3–6 weeks after surgery. In 2008, all patients underwent further telephone follow-up. Clinical variables abstracted for analysis included indication for surgery, patient age and sex, and perioperative complications. The response to surgical treatment was also defined with a long-term-result index (iLTR) scaled from 0 to 2. An iLTR of 2 means excellent, absence of hyperhidrosis symptoms. An iLTR of 1 reflects minimal to moderate postoperative symptoms affecting the patient's quality of life. An iLTR of 0 translates into pronounced symptoms representing major significant impact on the patient's quality of life. The iLTR for each individual was elicited for each postoperative year to characterize its changes over time. Statistical comparisons were performed using Fisher's exact test. To identify treatment associated side effects, patients were asked to comment on occurrence and location of any compensatory sweating (defined as excessive sweating after the operation that was considered abnormal), gustatory sweating (defined as abnormal facial sweating as felt by the patient when eating certain foods), postoperative paresthesias (defined as numbness or prickle at the trocar insertion sites, armpits or chest wall) and sustained pain at the trocar insertion sites. Finally, they were asked whether they were satisfied with or regretted the operation.

3. Results

We performed 60 thoracoscopic sympathicotomies in 31 patients (two unilateral approaches following contralateral surgery elsewhere). There were 10 women and 21 men. The mean age was 27±9 years (range, 14–59 years). All patients offered surgery were previously deemed intolerant or failed medical therapy for their symptoms. No conversion to open technique was necessary, and there was no operative mortality. Operative complications included one bleeding requiring hemostasis by thoracoscopy and one transient Horner's syndrome lasting four weeks.

For long-term analysis, 15 patients were retrieved (1 death, 15 patients lost to follow-up), representing 48.4% of the study population. Mean follow-up time was 12±2 years. A comparison between the group of operated patients and the group of patients available for follow-up showed an increased postoperative follow-up period in the latter, but no additional differences (Table 1 ).

Table 1

Comparison of operated patients and patients retrieved for follow-up

 Operated Completed  
 patients follow-up  
Patient demographics 
n 31 15 (48.4%)  
 Sex (m:w) 21:10 10:5 ns 
  (%) (68:32) (66:33)  
 Age (years) 28±9 27±9 ns 
  Range 14–59 14–42  
Follow-up (years) 11±2 12±2 P=0.03 
    
Distribution of hyperhidrosis 
 Palmar n (%) 28 (90) 13 (87) ns 
 Axillar n (%) 16 (52)  7 (47) ns 
 Plantar n (%)  9 (29)  5 (33) ns 
 Operated Completed  
 patients follow-up  
Patient demographics 
n 31 15 (48.4%)  
 Sex (m:w) 21:10 10:5 ns 
  (%) (68:32) (66:33)  
 Age (years) 28±9 27±9 ns 
  Range 14–59 14–42  
Follow-up (years) 11±2 12±2 P=0.03 
    
Distribution of hyperhidrosis 
 Palmar n (%) 28 (90) 13 (87) ns 
 Axillar n (%) 16 (52)  7 (47) ns 
 Plantar n (%)  9 (29)  5 (33) ns 

ns, Not significant.

For the entire study population, the iLTR characterizing the individual response to surgical treatment significantly decreased over time (iLTR12 years 1.18±0.6 vs. 1.87±0.52, P=0.01), indicating a continous deterioration of the operative result. To investigate to what extent the preoperative complaints affected the surgical outcome, we refined the analysis by considering the preoperative site of hyperhidrosis (Table 2 ). The subgroup analysis revealed no differences (Fig. 1 ). Patients with isolated palmar hyperhidrosis had the most favourable immediate postoperative results (iLTR 2±0.0) compared to patients with additional axillar or plantar involvement [iLTR 1.71±0.76 (P=0.36) and 1.6±0.89 (P=0.37)].

Fig. 1.

Long-term result index (iLTR) for entire study population (overall) and its subgroups defined by preoperative site of hyperhidrosis.

Fig. 1.

Long-term result index (iLTR) for entire study population (overall) and its subgroups defined by preoperative site of hyperhidrosis.

We detected a high prevalence of treatment associated side effects with nine patients having compensatory sweating (60%), five patients indicating gustatory sweating (33%), and eight patients mentioning chest wall paresthesias (53%). One patient furthermore complained about recurrent pain in the armpits. Overall, seven patients were satisfied with the operative result (47%), two were ambivalent and six patients regretted outcome (40%).

To find out if surgical side effects preponderate operative results and, therefore, account for the unfavourable patients' appraisal of surgical treatment, we compared iLTR and surgical side effects amongst disappointed patients (n=6) and the others (n=9). It turned out that iLTR of the former group ranged below the arithmetic mean (Fig. 2a ). The comparison of treatment satisfaction and preoperative hyperhidrosis allocation revealed that, in particular, patients with axillary manifestation were disappointed with the surgical outcome (Fig. 2b). Evaluating the impact of procedure-related side effects on patient satisfaction, it turned out that the relative occurrence of compensatory sweating and chest wall paresthesias was higher in the group of patients with a more favourable rating of the surgical outcome (Fig. 2c).

Fig. 2.

Surgical success and side effects in satisfied and disappointed patients. (a) Long-term result index (iLTR). (b) Patient satisfaction contingent on preoperative site of hyperhidrosis. (c) Clinical manifestation of side effects (CS, compensatory sweating, GS, gustatory sweating).

Fig. 2.

Surgical success and side effects in satisfied and disappointed patients. (a) Long-term result index (iLTR). (b) Patient satisfaction contingent on preoperative site of hyperhidrosis. (c) Clinical manifestation of side effects (CS, compensatory sweating, GS, gustatory sweating).

4. Discussion

Hyperhidrosis is an idiopathic condition that is characterized by secretion of sweat in amounts greater than physiologically needed for thermoregulation. Medical management including topical or oral agents and iontopheresis offers only minimal and temporary relief [7]. Endoscopic thoracic sympathicotomy represents a well-described surgical approach that is based on the interruption of impulse-transmission from the sympathetic ganglia to the sweat glands. Several technical modifications of the surgical approach have been described with varying access sites and different operative approaches (resection of the sympathetic chain, simple chain division over the ribs, or selective sympathicotomy) [4,8,9]. Significant improvement in quality of life can result from surgery, in particular in patients with isolated palmar hyperhidrosis. However, numerous studies have shown a high proportion of thermoregulatory side effects in operated patients, referred to as gustatory sweating (GS) and compensatory sweating (CS), with the latter being the most common. These hitherto inexplicable reactive mechanisms may negatively impact the quality of life in patients after the operation [1,2,5]. Since it has been realized that the incidence of postoperative CS appears to be dependent on the level and extent of sympathicotomy performed, there is an ongoing debate among thoracic surgeons on the ideal strategy to attack the sympathetic chain [5,8]. At this, surgeons have to balance reducing the incidence of CS against ensuring relief of the primary symptoms. Unfortunately, consolidated findings regarding the sustainability of the surgical success and the negative impact of CS on the patient's quality of life for more than five years are rare.

We conducted a retrospective analysis of all patients that underwent endoscopic thoracic sympathicotomy between 1992 and 1997. Forty-eight percent of patients were retrieved 12±2 years after their operation. In our study, we identified a significant deterioration of the surgical efficacy over time and a high prevalence of surgery elicited side effects including CS, GS, chest wall paresthesias and perseverative pain. Patient satisfaction more than 10 years after surgery was a disappointing 60%. Subgroup analyses revealed that patient dissatisfaction was primarily associated with impaired preoperative symptom relief and to a lesser extent with the incidence of side effects.

The fragmentary patient follow-up and the small number of patients bear the risk to bias the study results. However, a comparison of the operated patients and the group of patients included in this study revealed no disparities. Few studies do report a long-term follow-up [1,2,4,8,10–13] because following these patients is difficult (Table 3 ). They are usually young, thus relocate frequently, and do not see the need for surgical control once they have been treated. Thus, some consequences of the operation remain in the background, for example, postoperative pain or hand dryness. Conversely, side effects like CS are often not perceived. Evaluating the global result of the operation is, therefore, difficult [8].

Table 3

Long-term follow-up studies for endoscopic thoracic sympathicotomy

 Study Patients Follow-up Follow-up Recurrence Compensatory Gustatory Pain Patient 
 period (ntime (months) (% patients) rate (%) sweating (%) sweating (%) (%) dissatisfaction 
         (%) 
Zacherl et al. [2] 1965–1996  320 Ø193.2 (12–324) 83.3 <0.1 67.2 47.4 n.r. 6.5 
Rex et al. [4] 1989–1996 1152 Ø38 (4–88) 90.0   0.6–5.5 59.8 28.0 n.r. 10.2 
Lin et al. [10] 1993–2000 2000 Ø51.7 (6–89) 100   0–4.1 86 n.r. n.r. n.s. 
Dumont et al. [1] 1994–2000  124 Ø36 (6–78) 72.0   2 87 4.0 78 # 10 
Gossot et al. [8] 1993–2001  530 Ø46 (24–48) 33   9 86.4 7.2 n.r. 6.3 
Reisfeld et al. [11] 1996–2001 1312 Ø22.6 (1–50) 100   3 94 5.5 n.r. 
Doolabh et al. [12] 1997–2002  180 Ø17 (0–60) 100   2 76 n.r. 
Licht and Pileguard [13] 1997–2005  238 Ø17 (0–72) 96.2   3.5 90 32 n.r. 14 
 Study Patients Follow-up Follow-up Recurrence Compensatory Gustatory Pain Patient 
 period (ntime (months) (% patients) rate (%) sweating (%) sweating (%) (%) dissatisfaction 
         (%) 
Zacherl et al. [2] 1965–1996  320 Ø193.2 (12–324) 83.3 <0.1 67.2 47.4 n.r. 6.5 
Rex et al. [4] 1989–1996 1152 Ø38 (4–88) 90.0   0.6–5.5 59.8 28.0 n.r. 10.2 
Lin et al. [10] 1993–2000 2000 Ø51.7 (6–89) 100   0–4.1 86 n.r. n.r. n.s. 
Dumont et al. [1] 1994–2000  124 Ø36 (6–78) 72.0   2 87 4.0 78 # 10 
Gossot et al. [8] 1993–2001  530 Ø46 (24–48) 33   9 86.4 7.2 n.r. 6.3 
Reisfeld et al. [11] 1996–2001 1312 Ø22.6 (1–50) 100   3 94 5.5 n.r. 
Doolabh et al. [12] 1997–2002  180 Ø17 (0–60) 100   2 76 n.r. 
Licht and Pileguard [13] 1997–2005  238 Ø17 (0–72) 96.2   3.5 90 32 n.r. 14 

n.r., Not reported; #reported as pain after hospital release; n.s., not specified; Ø, average follow-up.

During the study period, we performed selective sympathicotomies (with preservation of the sympathetic trunk and division of the rami communicantes) for treating hyperhidrosis on the basis of previous reports indicating a decreased rate of CS [9]. Although there is, at present, no consensus for the ideal surgical procedure [5,6], this technique has been widely abandoned since surgeons performing this limited approach had to face early relapses [8]. Our dissatisfactory long-term efficacy reflected in a continually deteriorating iLTR may therefore – at least in part – be allegeable by the applied surgical technique. However, other groups applying different surgical techniques have also experienced symptom recurrences (Table 3). In contrast to previous reports that recurrences usually arise within the first 18 months after surgery [14], we identified a slowly progressing worsening of our operative results, thus strengthening the need for more long-term follow-ups to elucidate the disease and healing process.

GS was 33% in our study. In previous reports, its incidence varies from 3 to 47% (Table 3), but it is generally underreported as both clinicians and patients do not view it as unduly troublesome [7].

In coherence with numerous previous studies, we identified CS as the major drawback of thoracic sympathicotomy. Rates have been reported from as low as 30% to as high as 90% [3,4] (Table 3) with incidence and degree of CS appearance to depend on the extent of resection of the sympathetic chain [12]. However, the vast majority of patients still express high satisfaction with the results of surgery with respect to the alleviation of their primary symptoms [5]. In contrast to previous studies reporting a decrease of CS in severity and extent over time [14], our experience demonstrates that CS was still present after more than 12 years and patients did not report improvement with time, supporting findings of Gossot et al [8].

The high rate of postoperative paresthesias and one patient with perseverative pain was a surprising finding. While these sequels have been identified in almost 32% of patients undergoing various thoracoscopic procedures [15], they are underreported in the published endoscopic thoracic sympathectomy literature (Table 3).

The dramatic efficiency of surgery on hyperhidrosis, in particular in patients with sole palmar manifestation, has made endoscopic thoracic sympathicotomy popular among patients and physicians [8]. The benign nature of the disease mandates that any medical intervention should be extraordinarily safe, minimally invasive, and produce fewer side effects than the original disease [5]. Current work is focusing on different methods of performing endoscopic thoracic sympathicotomy, by clipping rather than cutting, for example [3], or by concentrating the surgical attack at different levels of the chain for different conditions [3,5]. Therefore, future refinements of surgical techniques should take into consideration both, the potential for clinically significant CS as well as the potential for loss of treatment efficacy. Our study shows that patient satisfaction requires preoperative symptom relief more than absence of side effects. By showing this, our findings may help to reach a consensus on the standard operation of hyperhidrosis.

Presented at the 16th European Conference on General Thoracic Surgery, Bologna, Italy, June 8–11, 2008.

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