T2 Sympathectomy Research Articles

Long-term outcomes of bilateral thoracoscopic T3 sympathectomy for primary focal hyperhidrosis in children

BackgroundThoracoscopic bilateral T3 sympathectomy for primary focal palmar hyperhidrosis in children has excellent short-term outcomes. However, data in the literature, on the long-term outcomes of the operation are scarce. MethodsWe conducted a retrospective institutional review of all children and adolescents undergoing T3 bilateral thoracoscopic sympathectomy for primary focal palmar hyperhidrosis between June 2013 and October 2020. We composed a quality of life (QoL) questionnaire evaluating the patient's perception of how much the hyperhidrosis affected their daily life in multiple domains. The questionnaire was completed before the operation and at every postoperative follow-up visit. ResultsWe operated on 58 patients with a median age of 15 (6–25) years. There were no intraoperative or postoperative complications, and all patients had immediate complete postoperative resolution of their palmar hyperhidrosis. Fifty-three patients (91.4%) had long-term follow-up data available with a median of 2.5 (range 0.1–7.5) years. Two patients (3.4%) experienced recurrence of their palmar hyperhidrosis. Nine patients (15.5%) experienced compensatory hyperhidrosis and required occasional medical management with oral anticholinergics. Two patients reported regretting having undergone the operation. Overall, the mean QoL score improved remarkably, from 42/100 before the operation to 92/100 at 1 month, 89/100 at six months to a year, 97/100 between two and four years, and 80/100 ≥ 5 years after the operation. ConclusionThoracoscopic bilateral T3 sympathectomy has a high success rate for primary palmar hyperhidrosis in children in the mid- to long-term. Compensatory sweating and recurrence can occur years after the operation, so long-term follow up is mandatory. Level of evidenceIV.

Repeated Single Level Lumbar Sympathetic Neurolysis using Alcohol in a Plantar Hyperhidrosis Patient: A 5-year Follow-up Case Report

Background: Plantar hyperhidrosis causes discomfort in daily life. However, there are few reports on sympathetic neurolysis in plantar hyperhidrosis. Case: A 19-year-old woman complained of excessive sweating of both hands and feet. Using video-assisted thoracic surgery, the patient underwent bilateral T3 sympathectomy in the department of chest surgery. One year later, she visited pain clinic with with plantar hyperhidrosis and wanted to undergo sympathetic block. Lumbar sympathetic neurolysis was performed using 2.5 ml of pure anhydrous alcohol at the L4 vertebral level. The symptoms improved after the procedure, and there were no side effects. The patient again underwent sympathetic neurolysis as the symptoms recur. Conclusions: Repeated lumbar sympathetic neurolysis was performed in a patient with plantar hyperhidrosis, and its success was confirmed during 5 years of follow-up.

Thoracoscopic T2-T3 versus T4 sympathectomy for primary palmar hyperhidrosis in children and adolescents: a randomized comparative study

BackgroundControversy exists regarding the appropriate level of sympathectomy for primary palmar hyperhidrosis (PH) as different levels are associated with variable postoperative patients’ satisfaction and potential complications. The aim of this study was to investigate the safety, efficacy, and outcome of T2-T3 thoracoscopic sympathectomy (TS) versus T4 TS in this age group.ResultsThis prospective study included 32 patients (17 males and 15 females) with primary PH treated at the department of pediatric surgery, in our institution during the period from February 2019 to February 2020. Inclusion criteria included moderate and/or severe degrees of PH not responding to conservative measures. The patients were divided randomly into two groups: group I treated by T2-T3 TS and group II underwent only T4 TS. All patients were evaluated regarding operative details and postoperative outcome. Follow-up ranged from 6 to 24 months. Group I included 18 patients (14 operated on both sides and 4 operated on one side), and group II included 14 patients (11 operated on both sides and 3 operated on one side). The ages ranged between 5 and 18 years (mean 14.25 ± 3.14 years). The difference in mean age among both groups (14.5 versus 13.9 years) was not statistically significant. The mean operative time was significantly longer in group I (22.4 versus 17.2 min, p value 0.046). The hospital stay (1 day) was similar for both groups. Postoperative compensatory hyperhidrosis (CH) was more frequent in group I (n=7, 50% versus n=5, 45.5%), but the difference was not statistically significant. Postoperative over dryness occurred in 5 patients in group I (28.6%) and temporary Horner’s syndrome in one patient (7.14%). No over dryness or Horner’s syndrome occurred in any patient in group II. The QOL score has improved in both groups; the degree of improvements was better in group II.ConclusionBoth T2-T3 TS and T4 TS are effective in treating primary palmar hyperhidrosis in children and adolescents. T4 TS is preferred than T2-3 TS due to less frequent postoperative complications and better patients’ satisfaction.

Long-Term Efficacy of T3 Versus T3+T4 Thoracoscopic Sympathectomy for Concurrent Palmar and Plantar Hyperhidrosis

BackgroundMore than 50% of patients with palmar hyperhidrosis (PAH) also have plantar hyperhidrosis (PLH). We compared the long-term results of T3 sympathectomy with those of combined T3+T4 sympathectomy among patients with concurrent PAH and PLH. Materials and methodsWe retrospectively analyzed the records of patients with concurrent PAH and PLH who underwent T3 alone or T3+T4 sympathectomy from January 1, 2012, to December 31, 2017. Preoperative and postoperative sweating (hyperhidrosis index) was evaluated through questionnaires, physical examination, and outpatient follow-up. The relief rates and hyperhidrosis index were used as outcome measures to compare the efficacy of the two approaches. Patients’ satisfaction and side effects were also evaluated. ResultsOf the 220 eligible patients, 60 underwent T3 sympathectomy (T3 group), and 160 underwent T3+T4 sympathectomy (T3+T4 group). Compared with the T3 group, the T3+T4 group showed higher symptom relief rates both for PAH (98.75% versus 93.33%, P = 0.048) and PLH (65.63% versus 46.67%, P = 0.01), and a greater postoperative decrease in both hyperhidrosis indices. The rate of severe compensatory hyperhidrosis also increased (10% versus 5%, P = 0.197), although the rates of overall satisfaction were comparable between the groups. The incidence of postoperative pneumothorax requiring chest tube placement and postoperative neuralgia was also similar. There were no cases of perioperative death, secondary operation, wound infection, or Horner syndrome in either group. ConclusionsCompared with T3 alone, T3+T4 sympathectomy achieved a higher symptom relief rate and a lower hyperhidrosis index. T3+T4 sympathectomy may be a choice for the treatment of concurrent PAH and PLH; however, patients need to be informed that this kind of surgery may increase the risk of compensatory sweating.

Heart rate variability as a potential diagnostic tool to predict compensatory hyperhidrosis after sympathectomy in patients with primary focal hyperhidrosis.

BackgroundPrimary focal hyperhidrosis (PFH) is associated with autonomic nervous activity, and studies investigating this association in patients with PFH are very important. Heart rate variability (HRV) is a simple and noninvasive electrocardiographic test showing activity and balance in the autonomic nervous system, which consists of sympathetic and parasympathetic components. The aims of this study are to investigate associations between autonomic nervous activity and hyperhidrosis characteristics using HRV and to investigate the association between HRV findings and compensatory hyperhidrosis (CH) after sympathectomy.MethodsFrom March 2017 to March 2020, 105 subjects with PFH who underwent preoperative HRV tests and sympathectomy were analyzed. All subjects underwent bilateral thoracoscopic sympathectomy. T2 sympathectomy was conducted for craniofacial hyperhidrosis, and T3 sympathectomy was conducted for palmar hyperhidrosis. The following HRV parameters chosen to investigate the association between hyperhidrosis and autonomic nervous activity were measured by time and frequency domain spectral analysis: (I) time domain: standard deviation of normal-to-normal interval (SDNN) and square root of mean squared differences of successive normal-to-normal intervals (RMSSD), (II) frequency domain: total power (TP) of power spectral density, very low frequency (VLF), low frequency (LF), and high frequency (HF). HRV parameters were analyzed according to hyperhidrosis type (craniofacial vs. palmar type), sweat reduction, and CH after sympathectomy. In addition, the independent HRV parameters influencing CH after sympathectomy were investigated with multivariate analysis.ResultsCraniofacial hyperhidrosis was significantly more prevalent in the old age group (P<0.001). Sweat reduction after sympathectomy was significantly more prominent in palmar hyperhidrosis (P=0.037), and CH after sympathectomy was more prominent in craniofacial hyperhidrosis (P<0.001). Palmar type patients exhibited significantly larger SDNN, RMSSD, TP, LF, and HF than craniofacial type patients (all P<0.001). There were no significant differences in any HRV parameters according to sweat reduction after sympathectomy. Low-degree CH was associated with significantly larger SDNN, RMSSD, TP, LF, and HF than high-degree CH (P<0.001, P<0.001, P=0.002, P=0.001, and P<0.001, respectively). Multivariate analysis showed that HF and age group were associated with CH after sympathectomy (P=0.007 and P=0.010, respectively).ConclusionsThis study shows that HRV can provide useful insight into the pathophysiology of PFH and enhance preoperative risk stratification of CH. Large-scale, prospective studies are required to determine the predictive value of HRV in patients at risk for subsequent CH after sympathectomy.

Video-assisted thoracoscopic sympathectomy for thoracic three versus thoracic four for the treatment of primary hyperhidrosis (single-center study)

Background Hyperhidrosis is a pathologic disease of excessive sweating in amounts greater than the physiologically necessary thermoregulation. Although hand sweating does not have a significant effect on the health of patients, it can be uncomfortable to shake hands, complicate the writing, and cause humiliation and psychological distress. The primary treatment for patients with the disease is video-assisted thoracic sympathectomy (VATS) to be done with accuracy, with improved health care and good outcomes. Aim The aim was to assess the effect VATS on patient’s quality of life according to the level of sympathectomy performed, as well as the presence of postoperative complications. Patients and methods This is a comparative randomized study that was conducted at Al-Zahraa University Hospital. A total of 126 patients with palmar hydrosis were involved in this study. The authors included patients from 16 to 40 years, in whom the sweating had a negative effect on their work. The authors have classified patients into two groups, those who underwent VATS on T3 and those who on T4 level, randomly. The authors followed patients at 1, 6, 12, and 24 months. Results The study was conducted on 126 patients, comprising 27.7% males and 72.3% females, with mean age of 25.8+5.8 and 25.2+4.4 in T3 and T4 groups, respectively. The incidence of compensatory hyperhidrosis was significantly lower in T4 group at 6 and 12 months, and also it was lower at long-term follow-up of 24 months, but with no significance statistically. We have noticed high rates of satisfaction of different degrees in both groups. T4 group showed better efficacy in limiting compensatory hyperhidrosis compared with T3 group. Conclusion Thoracoscopic T4, T3 sympathectomy provides very good results, with very low incidence of compensatory hyperhidrosis. T4 appears to be the best segment for treatment of primary hyperhidrosis.

The Best Thoracic Sympathectomy Level for Palmar Hyperhidrosis: a Meta-analysis

Palmar hyperhidrosis (PH) refers to excessive sweating that affects patients’ quality of life, resulting in social and work impairment and emotional distress. Thoracic sympathectomy (TS) is the best surgery option for palmar hyperhidrosis; however, there was no agreement for the choice of optimal surgery level. The aim of this study was to systematically compare postoperative effect between thoracoscopic T3 and T4 thoracic sympathectomy for palmar hyperhidrosis and to help clinical decision. Studies comparing T3 versus T4 thoracic sympathectomy for palmar hyperhidrosis were searched overall the database and a meta-analysis was performed. After searching, 12 articles were selected and a total of 1192 patients with palmar hyperhidrosis, of whom 567 patients underwent T3 thoracic sympathectomy and 625 patients underwent T4 thoracic sympathectomy. After analysis, we found that T4 thoracic sympathectomy had fewer side effects than T3 thoracic sympathectomy, so T4 may be the optimal level for thoracic sympathectomy in palmar hyperhidrosis patients.

Sympathectomy for lymphedema: A case series

Breast cancer-related lymphedema (BCRL) is an increasingly common complication seen in the palliative care setting due to increased life expectancy of breast cancer survivors. It is an important determinant of the quality of life of breast cancer survivors, due to the functional impact that it has, apart from the pain and deformity associated with it. Conservative management of lymphedema with the help of physiotherapy, positioning, manual lymphatic drainage, and intermittent pneumatic compression is well known. Even then, there remains a subset of patients that fail to respond to conservative management. T2 sympathectomy is a technique which ablates the thoracic sympathetic chain and helps in improving the lymphatic drainage. We report a series of four cases of BCRL, which showed a significant reduction in the mid-arm circumference as well as pain scores after a T2 sympathectomy. We believe that T2 sympathectomy can be used as the second line of management in lymphedema patients in whom conservative treatment has failed.

A retrospective cohort study of T3 versus T4 thoracoscopic sympathectomy for primary palmar hyperhidrosis and primary palmar hyperhidrosis with axillary and plantar sweating.

IntroductionThoracoscopic sympathectomy (TS) has been proven to be a safe and effective treatment for primary palmar hyperhidrosis (PH). However, the complications include compensatory hyperhidrosis (CH), and over-dry hands may occur in some patients after TS.AimTo compare the therapeutic effect of T3 and T4 TS on primary PH and primary PH with axillary and plantar sweating.Material and methodsWe retrospectively analyzed 100 patients with PH who had undergone T3 (group A, n = 49) or T4 (group B, n = 51) TS in our department, with at least 1 year of postoperative follow-up.ResultsAt discharge, no major complications or deaths occurred in either group. The condition of sweaty hands was fully improved in 44 of 49 patients in group A and all patients in group B, with a significant difference (p = 0.031). After 12 months of follow-up, 18 (36.7%) patients in group A and 4 (7.8%) patients in group B developed CH, 16 (48.5%) patients in group A and 24 (77.4%) patients in group B had improved axillary sweating, with a significant difference (p < 0.05). The satisfaction rate of group B was significantly higher than that of group A (p < 0.01).ConclusionsBoth T3 and T4 TS were safe and effective treatments for PH patients, but the incidence of CH in T4 TS was lower than that in T3 TS. T3 TS may be more suitable for patients with severe PH, while T4 TS had a better therapeutic effect on PH patients with axillary sweating.

Is there any relationship between quality of life and the level of sympathectomy in primary palmar hyperhidrosis? Single-center experience

The discussions at the surgical levels (sympathectomy levels) about endoscopic thoracic sympathectomy (ETS) method, which is applied in hyperhidrosis treatment in the present day and acknowledged as the golden treatment method, continue. Mainly, most of the studies evaluates postoperative early period results. Our aim in this study is to compare the long-term quality of life depending on the different surgical levels (sympathectomy levels) and evaluate the postoperative complications. 165 patients operated due to palmar hyperhidrosis between January 2012 and July 2017 were evaluated. Sympathectomy was performed either by clipping or cauterization and sympathetic nerves included were T2-4, T3-4, or T3 levels. Data were retrospectively reviewed for complications, factors affecting the postoperative quality of life. Ninety of the patients were male (54.5%) and 75 (45.5%) were female. The level of ganglion block was T2-T4 in 62 patients (37.6%), T3-T4 in 46 patients (27.9%), and T3 in 57 patients (34.5%). Early complications were observed in 27 patients (16.4%). Compensatory hyperhidrosis (CH) was observed in 62 patients (37.6%). There was a significant difference in the postoperative quality of life according to ETS level (p < 0.001). Patients who underwent T2-T4 sympathectomy had a lower quality of life than patients who underwent isolated T3 or T3-T4 sympathectomy. Based on our results, we recommend performing lower level resections to increase the long-term quality of life in palmar hyperhidrosis patients. The lower risk of CH and comparable quality of life suggest that T3 sympathectomy is more effective.

A comparative study of thoracoscopic sympathectomy for the treatment of hand sweating.

To compare postoperative satisfaction, compensatory hyperhidrosis, and the quality of life between thoracoscopic T3 and T4 sympathectomy for the treatment of hand sweating. From December 2010 to October 2014, 192 consecutive patients with hand sweating underwent a thoracoscopic bilateral sympathectomy with different planes (T3/T4). The patients were randomly divided into two groups, the T3 and the T4 groups, for those who underwent thoracoscopic T3 and T4 sympathectomy, respectively. All patients underwent double-lumen intubation during the thoracoscopic bilateral sympathectomy. The patients were followed up with by telephone for postoperative evaluation on the safety and effectiveness of the procedure, and the two groups (T3 versus T4) were compared to each other for any potential differences. All of the patients' sweating symptoms improved after the procedure. The incidence of compensatory hyperhidrosis and palm dryness in the T4 group was lower than that in the T3 group (P<0.05). The satisfaction rate and the rate of improvement in sweating and the incidence of palm moisture in the T4 group were higher than those in the T3 group (P<0.05). Thoracoscopic T3 and T4 sympathectomy are safe and effective methods for the treatment of hand sweating. Lowering the sympathetic chain resection plane can increase patients' satisfaction and enhance improvements in sweating. It can also reduce the incidence of long-term compensatory hyperhidrosis and palm dryness, but it also increases the incidence of palm moisture.

Impact of Thoracoscopic T2 Sympathectomy on Patients With Primary Palmar and Axillary Hyperhidrosis

There are different techniques for thoracoscopic sympathectomy for management of primary hyperhidrosis. Each technique has the advantage of giving good surgical results, but may cause complications, which depend on the level of sympathectomy used in each technique. From October 2012 to August 2016, a total number of 120 patients (of primary palmar and axillary hyperhidrosis) were enrolled in this prospective randomized study. Patients were randomized preoperatively and divided into 2 groups: group A (underwent T2, T3, and T4 sympathectomy) and group B (underwent T3 and T4 sympathectomy) with 1 year of follow-up. Improvement of palm sweating, development of complications, patient satisfaction, and quality of life were evaluated. Family history was positive in 33 patients (55%) in group A and in 31 patients (52%) in group B. All patients had improvement of hand sweating. Overdry hands were significant in group A (p= 0.032). Compensatory sweating was significant in group A after the first month (p= 0.016), after 6 months (p= 0.022), and after 12 months (p= 0.025). In group B, very satisfied patients were significant after 6 and 12 months (p= 0.002 and 0.000, respectively). Limited sympathectomy to the level of T3 and T4 has the same therapeutic effect obtained by T2, T3, and T4 sympathectomy with less complications, greater patient satisfaction, and better quality of life. It should be the technique of choice for treatment of primary palmar and axillary hyperhidrosis.

Comparison of T2 and T3 sympathectomy for compensatory sweating on palmar hyperhidrosis.

Background:An otherwise successfully performed endoscopic thoracic sympathectomy (ETS) to treat palmar hyperhidrosis (PH) often has a serious side effect: compensatory sweating (CS). This side effect occurs in other parts of the body to a disturbing extent. The objective of this study is to determine whether there is a relationship between the level of ETS performed on patients with PH, and the occurrence and severity of postoperational CS.Methods:Between January 2014 and January 2015, ETS procedures were performed on 25 randomly selected consecutive subjects (group A) at T2 level, and on another 25 subjects (group B) at T3 level, who all felt severely handicapped due to PH. All subjects were assessed in terms of their demographic characteristics including gender and age, as well as postoperative complications, short-term results, side effects, recurrence of symptoms, and long-term results.Results:The symptoms disappeared in all subjects in short-term, and no recurrence was seen in their short or long-term follow-ups. At the end of year one, CS developed at a rate of 12% in group A and 8% in group B, particularly in their back and abdominal regions. The overall satisfaction with the procedure in year one was 96% in group A and 100% in group B.Conclusion:When an ETS performed at T2 or T3 level for PH involves only the interruption of the sympathetic chain, with a limitation on the range of dissection and avoidance of any damage to ganglia, sweating is stopped completely. No recurrence of PH is encountered, and CS develops only at low rates and severities.

Thoracoscopic bilateral T3 sympathectomy for primary focal hyperhidrosis in children

Aim of the studyPresent our experience in the surgical treatment of primary focal hyperhidrosis of the hands by thoracoscopic bilateral T3 sympathectomy in pediatric patients. MethodsRetrospective chart review of all patients operated between 2013 and 2015. ResultsWe operated and included in the study 28 patients, 22 females and 6 males. Mean age was 14 (6–21) years. All patients had previously tried at least one form of medical therapy with no success. All patients were extensively counseled regarding the potential side effects of the sympathectomy. The operations were done in supine position with the arms extended. All patients were intubated with a double-lumen endotracheal tube for sequential lung isolation. We used a 5-mm port for the scope and a 3-mm port for the instruments, both placed in the axilla. The third rib was identified by fluoroscopy. The sympathectomy was done with monopolar cautery. Mean operative time was 43 (25–71) minutes. No chest tubes were used. The incidence of intraoperative or postoperative complications was zero. All patients were discharged within the first 24 postoperative hours. All patients achieved immediate complete postoperative resolution of the palmar hyperhidrosis, sustained in all cases at a median follow-up of 17 (2–34) months. The mean preoperative quality of life score (based on a multifunctional self-assessment questionnaire) was 41/100, whereas after the operation, it was 92/100. Only 1 patient developed temporary compensatory sweating. All patients were satisfied with the result of the operation. ConclusionThoracoscopic bilateral T3 sympathectomy is a safe and effective treatment for children and adolescents with primary focal hyperhidrosis of the hands who failed medical management and have a very low rate of compensatory sweating. Level of evidenceIV

Effects of T3 or T4 sympathectomy through transumbilical-ultrafine gastroscopy for primary palmar hyperhidrosis

Objective To compare the efficacy of transumbilical-ultrafine gastroscope sympathectomy for severe palmar hyperhidrosis using two distinct levels of T3 and T4. Methods A total of 84 cases with severe primary hyperhidrosis were randomly allocated to undergo either T3 sympathectomy treatment (T3 group, n=42) or T4 sympathectomy treatment (T4 group, n=42)with no difference between the two groups. The operation time, postoperative hospital stay, patient's hands hyperhidrosis, axillary hyperhidrosis, complications were recorded at follow-up in 1, 3, 6, 12 months. Results Operation on 84 patients were successful with mean operative time of T3 group being 55.02±10.61 min and T4 group being 55.36±10.51 min(P>0.05). The mean postoperative hospital stay were both 1.5 days. Patients were followed up for diaphragmatic hernia, umbilical hernia, Horner's syndrome and other serious complications for 12 months.No postoperative recurrence of palmar hyperhidrosis, severe compensatory sweating occurred in either group. The number of improved patients in T3 group's palmar hyperhidrosis, axillary hyperhidrosis, and foot hyperhidrosis were: 42/42 cases, 10/16 cases, 21/29 cases, while those in T4 group were: 42/42 cases, 16/17 cases 18/28 cases. Axillary hyperhidrosis improved to a larger extent in T4 group than in T3 group(P<0.05). There were 16(15 mild and 1 moderate)compensatory sweating in T3 group and 7(6 mild and 1 moderate)compensatory sweating in T4 group(P<0.05). Conclusion T3 and T4 thoracic sympathectomy using transumbilical-ultrafine gastroscope for primary palmar hyperhidrosis are safe, effective, and feasible. T4 sympathectomy is more effective in improving axillary hyperhidrosis than T3 and shows lower occurrence of postoperative compensatory hyperhidrosis. Key words: Ultrafinegastroscope; Primary palmar hyperhidrosis; Thoracic sympathectomy; Compensatory sweating

Treatment of Primary Craniofacial Hyperhidrosis: A Systematic Review.

Primary craniofacial hyperhidrosis (CH) can have a profoundly negative impact on quality of life. No comprehensive review of its management exists. The objective of this review is to present the best clinical evidence to guide CH management. A systematic review was performed using PRISMA guidelines. MEDLINE and EMBASE were searched from 1966 to 2014 for articles using the MeSH terms "Hyperhidrosis", "Head", "Neck" and synonymous text words. Inclusion criteria were experimental and observational studies addressing CH treatment. Two reviewers independently assessed study quality and analysed data. Of 833 references yielded, 27 met inclusion criteria and were analysed. Twenty-two studies evaluated T2 sympathetic ablation (Level III evidence). Outcome measures were subjective and mean follow-up was 29 months. Reported efficacy was high (70-100%), recurrence rates were generally low (0-8%) and complications largely transient (e.g. pneumothorax 0-1%). However, 8-95.4% experienced troubling compensatory sweating. One randomised controlled trial and one observational study evaluated botulinum toxin A (Level Ib and III, respectively). Both employed objective outcome measures and demonstrated similar findings. Efficacy was 100%, lasted a median of 5-6 months and frontalis muscle inhibition was the main adverse effect (50-100%). Three studies evaluated anticholinergic therapy: topical glycopyrrolate demonstrated high efficacy (96%) with minimal adverse effects (Level Ib) and oral oxybutynin demonstrated relatively high efficacy (80-100%) but with noticeable adverse effects (76.6-83.6%) (Level III). There are few quality studies evaluating CH treatment. Based on available evidence, we recommend topical glycopyrrolate, oral oxybutynin and intradermal botulinum toxin A as first-line therapies due to their efficacy and safety. T2 sympathectomy should be considered for patients refractory to first-line therapy.

Modeling of safe window for percutaneous thoracic sympathectomy.

Despite the many benefits of percutaneous thoracic sympathectomy, it also has serious complications such as pneumothorax. This study was conducted in order to determine the safe percutaneous entering window and angles for the needle during T2 and T3 thoracic sympathectomy avoiding pneumothorax. Transverse section of CT images that crosses at the middle of the T2 or T3 vertebral body was selected. Medial and lateral imaginary lines were drawn from the dorsoventrally midpoint on the lateral surface of the vertebral body (v) to the skin. The medial one was drawn to the skin medially as much as possible tangent to the vertebral body (vM). The lateral one was drawn to the skin tangent to parietal pleura (vL). c was defined as the point where the midsagittal line meets the skin. The distance cM and cL, the angle aM and aL made between the midsagittal line and vM or vL lines were measured. To determine the relations between patients' covariates and measured data, mixed-effect population analysis was performed for the cL, aL, and vL. In males, the mean values of cL were 85.3 and 79.2 mm for T2 and T3, respectively. In females, they were 71.5 and 63.7 mm for T2 and T3, respectively. Population analysis revealed that cL was best described with age, weight, gender covariates, and interindividual variability. The aL was best described with BMI and gender covariates. The covariates' relationship and interindividual variability resulting from the mixed-effect analysis enhanced individual prediction for safe widows.

Optimal level of sympathectomy for primary palmar Hyperhidrosis: T3 versus T4 in a retrospective Cohort study

BackgroundTo compare the results obtained with T3 versus T4 sympathectomy in treatment of primary palmar hyperhidrosis (PH). MethodsBy retrospective review of medical records of patients with PH who underwent thoracoscopic sympathectomy from February, 2009 to September, 2012. The patients were categorized into two groups: T3 group underwent T3 sympathectomy and T4 group underwent T4 sympathectomy. Patients were evaluated according to the results of sweating, compensatory hyperhidrosis (CH), degree of satisfaction, complications and recurrence. Mean follow up was 19 ± 7 months. ResultsA total of 274 consecutive patients with PH were included in this study. There were 169 females and 105 males, with mean age of 29 ± 11 years. 129 patients underwent T3 sympathectomy (T3 group). The T4 group included 145 patients who underwent T4 sympathectomy. 71.7% patients of T4 group did not complain of CH in comparison to 25.6% patients in group T3 (P = 0.001) and the incidence of mild to moderate CH was higher in the T3 group than T4 (64.4% vs. 26.9%; p = 0.001). T4 group showed a great significance in the (very satisfied category) in comparison to T3 group (P = 0.001). The incidence of over-dry hands was significantly lower in group T4 (0.7%, 1 out of 145) than in group T3 (8.5%, 11 out of 129). The recurrence rate was similar in the two groups (0.8% vs. 1.4%; P = 0.19). ConclusionVideo-assisted T3 or T4 sympathectomy is a safe and effective procedure for treatment of palmar hyperhidrosis. T4 sympathectomy appears associated with less severe dryness and CH than T3 sympathectomy at long-term follow-up.

Percutaneous T2 and T3 Radiofrequency Sympathectomy for Complex Regional Pain Syndrome Secondary to Brachial Plexus Injury: A Case Series

Complex regional pain syndrome secondary to brachial plexus injury is often severe, debilitating and difficult to manage. Percuteneous radiofrequency sympathectomy is a relatively new technique, which has shown promising results in various chronic pain disorders. We present four consecutive patients with complex regional pain syndrome secondary to brachial plexus injury for more than 6 months duration, who had undergone percutaneous T2 and T3 radiofrequency sympathectomy after a diagnostic block. All four patients experienced minimal pain relief with conservative treatment and stellate ganglion blockade. An acceptable 6 month pain relief was achieved in all 4 patients where pain score remained less than 50% than that of initial score and all oral analgesics were able to be tapered down. There were no complications attributed to this procedure were reported. From this case series, percutaneous T2 and T3 radiofrequency sympathectomy might play a significant role in multi-modal approach of CRPS management.

Percutaneous radiofrequency thoracic sympathectomy for refractory arrhythmogenic storms: first in man study of six cases

Background: Catheter ablation has been shown to be effective in the treatment of scar-related ventricular tachycardia (VT). In limited number of patients ablation therapy failed to stop all incessant or unstable VTs. Several case reports and series have described the role of thoracic sympathectomy (VATS) in the treatment of refractory VTs. Method: We report three cases of patients with arrhythmic storm and nearly incessant refractory VTs who were treated with a percutaneous radiofrequency T2 and T3 sympathectomy on the left side. Results: 1) 42-y-old man with severe dilation CMP (LVEF 20%), after ICD storming. Both endocardial and epicardial radiofrequency and later alcohol ablations of the arrhythmogenic substrate were performed with insufficient effect. 2) 58-y-old man with ARVD was admit with arrhythmogenic storm. Both endocardial and epicardial RF ablations didn't stop recurrent VTs. 3) 62-y-old man post MI arrhythmic storm with several ICD shocks, complex catheter ablation failed to lessen the number of VT epizodes. 4) 40 y-old man post MI after CABG with ICD storming and unsuccessful catheter ablation 5) 51 y-old man postmyocarditis CMP with arrhythmic storm and repeated epicardial/endocardial ablation 6) 89 y-old man with ischemic CMP with severely depressed LV function (LV EF 15%), BiV ICD with storming and three catheter ablations failed to stabilised the rhythm The patients were indicated for a local anaesthetic block of the left stellate ganglion under real-time ultrasound guidance. Following the block both heart rate and blood pressure droped more than ten percent and patient did not experience any significant ventricular tachycardias for more than a week. He was then scheduled for the RF T2 and T3 left thoracic sympathectomy which was performed in supine position under local anaesthesia and mild sedation. A multi-planar fluoroscopy was used for a guidance. Six RF lesions (3 for each needle, medial, cranial and caudad rotation of the curved tip) were used, at the temperature of 70°C, 90 sec each. 0.5ml of 6% phenol was applied at the end of procedure into each needle to complete the sympathicolysis. Patients were not experienced with any ICD shocks since the sympathetic denervation., in two repeated ATPs terminated VTs. Conclusion: RF upper thoracic sympathectomy may become a considerable option for patients with refractory ventricular arrthythmias not responding on medical and electroinvasive treatment.