Invited Commentary

Abstract

Thoracic sympathectomy is an appropriate treatment for properly selected patients with hyperhidrosis who have undergone failed conservative measures. In general the results and satisfaction after video-assisted thoracic sympathectomy are excellent for patients with palmar or palmar and axillary symptoms combined, but there is a subset who will be dissatisfied mainly due to severe compensatory sweating. Other reasons for dissatisfaction outside of complications would be inadequate control of symptoms or symptom recurrence. Despite the extreme variations in description of results and the multitude of different surgical techniques, there is a growing impression that limiting the number of sympathetic levels interrupted and avoiding, if possible, the interruption of the T2 ganglion may help reduce the incidence of severe compensatory sweating [1Li X. Yuan-Rong T. Lin M. Lai F.C. Chen J.F. Dai Z.J. Endoscopic thoracic sympathectomy for palmar hyperhidrosis: a randomized control trial comparing T3 and T2-4 ablation.Ann Thorac Surg. 2008; 85: 1747-1752Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar]. The problem is that previously reported attempts to minimize the surgical approach have been associated with an increased incidence of recurrence or inadequate control of symptoms [2Lee D.Y. Kim D.H. Paik H.C. Selective division of T3 rami communicantes (T3 ramicotomy) in the treatment of palmar hyperhidrosis.Ann Thorac Surg. 2004; 78: 1052-1055Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar]. There is a stunning variation in reported results in the literature; part of this may be due to variability in the sympathetic chain, but clearly a large portion of this discordance is due to nonstandard descriptions of anatomy, techniques, and results. In this manuscript Li and colleagues [3Li X. Tu Y.-R. Lin M. Lai F.-C. Chen J.-F. Miao H.-W. Minimizing endoscopic thoracic sympathectomy for primary palmar hyperhidrosis: guided by palmar skin temperature and laser Doppler blood flow.Ann Thorac Surg. 2009; 87: 427-431Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar] have postulated that a patient's surgery could be individualized to recognize possible anatomic variation by using intraoperative testing. Their use of skin temperature and Doppler blood flow changes to gauge adequacy of response, although somewhat arbitrary, is a commendable effort to try to use some “science” when making treatment decisions. By limiting the extent of sympathectomy, their goal was to minimize the risk for severe compensatory sweating, but still interrupt the sympathetic chain sufficiently to achieve an adequate clinical response. The goal of procedural efficacy for palmar symptoms seems to have been achieved at 1 year, but there still was an 8% dissatisfaction rate. Their reported data does not clearly define the reasons for this nor does it identify by extent of surgery the severe compensatory sweating that developed in 6% of patients. It is imperative that clinicians treating patients with hyperhidrosis come to an understanding as to descriptions of disease severity, treatment response, surgical techniques, and follow-up so that we can use the experience of a number of investigators to better understand how to advise and treat patients with severe hyperhidrosis. Organizations such as our thoracic societies and the International Society of Sympathetic Surgery (ISSS) can help encourage these efforts. Minimizing Endoscopic Thoracic Sympathectomy for Primary Palmar Hyperhidrosis: Guided by Palmar Skin Temperature and Laser Doppler Blood FlowThe Annals of Thoracic SurgeryVol. 87Issue 2PreviewLimiting the extent of sympathectomy in palmar hyperhidrosis was recently recognized as an effective method to minimize the incidence and severity of troublesome compensatory sweating. However, the levels at which transection should be performed remain controversial. In this study, we proposed that the level of ablation varies and should be adjusted for each individual patient. Guided by palmar skin temperature and laser Doppler blood flow, we try to find the correct target level in each case. Full-Text PDF