Thoracoscopic Sympathicolysis Research Articles

Over a decade of single-center experience with thoracoscopic sympathicolysis for primary palmar hyperhidrosis: a case series

BackgroundPrimary palmar hyperhidrosis is a severely debilitating condition that can affect patients of any age. We report our experience with thoracoscopic sympathicolysis in a large cohort of children less than 14 years of age.MethodsAll children who underwent thoracoscopic sympathicolysis from April 2005 through January 2017 were evaluated retrospectively. The procedure entailed bilateral bipolar fulguration of the second and third thoracic ganglia with transverse disruption of collateral nerve fibers along the third and fourth rib. Demographic information, as well as postoperative outcome, complications, and satisfaction were analyzed.ResultsOver the 12 year study interval, a total of 102 children underwent thoracoscopic sympathicolysis for palmar hyperhidrosis. Complete follow-up was available for 98 patients (median age 12 [range 5–14] years; 38 boys [39%]). Median follow-up was 4 [range 2–12] years. Complete palmar dryness was achieved in 93 (95%) cases. One patient suffered postoperative unilateral ptosis, 6 reported gustatory sweating, and 65 experienced compensatory sweating. Average postoperative rating on a 1 (lowest) to 10 (highest) rating scale was 9, with 97 (99%) patients saying that they would undergo the procedure again.ConclusionOur technique of thoracoscopic sympathicolysis in children was associated with very high postoperative satisfaction, despite a high rate of compensatory sweating and occasional autonomic gustatory sweating. Other more severe complications in this age group were rare.

Impact of T3 thoracoscopic sympathectomy on pupillary function: a cause of partial Horner’s syndrome?

Thoracoscopic bilateral sympathicolysis of the T3 sympathetic ganglia is an effective treatment for palmar hyperhidrosis, though not without potential complications and consequences such as Horner's syndrome. The objective of our study is to evaluate the repercussion of T3 sympathetic denervation on pupillary tone in patients with primary hyperhidrosis. A prospective descriptive study of 25 patients (50 pupils) ranging in age from 18 to 40 years with an indication of T3 sympathectomy for palmar hyperhidrosis or palmar-plantar hyperhidrosis from 1 December 2009 to 31 December 2010 was carried out. We excluded all patients with previous eye surgery or other ocular pathologies and those with pathologies that contraindicate denervation surgery and ocular study. All patients were evaluated before surgery and at 24 h and 1 month after sympathetic denervation. Pupil/iris (P/I) ratio was measured before and after instillation of sympathicomimetic eye drops containing 1% apraclonidine. No statistically significant differences were found when we compared the preoperative P/I ratio of the left eyes versus the right eyes (P = 0.917). We found statistically significant differences (P < 0.001) between the preoperative P/I ratio [0.40 mm (standard deviation, SD 0.07 mm)] and the postoperative basal ratio [0.33 (SD 0.05)] at 24 h. The P/I ratio at 24 h increased from 0.33 to 0.36 (SD 0.09), a nonsignificant increase (P = 0.45), after instillation of medicated eye drops. No differences were observed between the preoperative [0.40 (SD 0.07)] and 1-month basal values [0.38 (SD 0.07)], and instillation of apraclonidine no longer induced a hypersensitivity response. T3 sympathectomy leads to subclinical pupillary dysfunction with a tendency for miosis, even though this impairment is not generally evident on standard physical examination or reported by patients. This subclinical dysfunction may be caused by injury to an undefined group of presympathetic nerve cell axons in caudocranial direction that communicate with the cervical sympathetic ganglia and whose function is mydriatic pupillary innervation.

An assessment of plantar hyperhidrosis after endoscopic thoracic sympathicolysis

Endoscopic bilateral thoracic sympathicolysis (EBTS) is an effective and minimally invasive procedure used for patients with primary hyperhidrosis. The purpose of this study was to examine plantar hyperhidrosis before and after EBTS. A total of 198 patients with primary hyperhidrosis underwent 396 thoracoscopic sympathicolysis of ganglia T2-T3 in a prospective study. All completed a preoperative questionnaire, followed by a second questionnaire 12 months after the operation. The questionnaires evaluated sweating in the different body areas. Only the zones of anhydrosis were considered in delimiting the cutaneous expression of sympathetic ganglia T2-T3. Redistribution of perspiration as reported by the patients comprised significant reductions in palmar and axillary hyperhidrosis, and an increase in the zone of the trunk and popliteal region. The incidence of plantar anhydrosis and plantar hypohidrosis was 30.3% and 20.7%, respectively (p < 0.001). EBTS is followed by redistribution of body perspiration, with, and important, plantar anhydrosis and hypohidrosis. Although EBTS is the standard treatment for palmar primary hyperhidrosis, we must continue studying baseline sympathetic activity in patients affected by primary hyperhidrosis and the neuroanatomy of the sympathetic system to understand the redistribution of sweating and decrease of hyperhidrosis in the zones regulated by mental or emotional stimuli.

Quantification of eccrine sweat glands with acetylcholine sweat-spot test and anatomical redistribution of sweating after T2–T3 thoracoscopic sympathicolysis

In this study, patients treated by thoracoscopic sympathicolysis for palmar hyperhidrosis were evaluated to determine the number and response of sweat glands to intradermal acetylcholine stimulus. A total of 30 patients were included in the study. Group A consisted of 10 patients with palmar hyperhidrosis who underwent thoracoscopic sympathicolysis in October 2005, and group B consisted of 20 patients who underwent surgery during the years 1999, 2000, and 2001. The study procedure involved applying iodine alcohol to the palm and then intradermally injecting 0.1 ml 1% acetylcholine. This activated the sweat glands, which were then photographed and counted. The study procedure was performed prospectively over different periods in group A and retrospectively in group B. In group A, the mean number of glands activated 1, 3, 6, and 12 months after surgery were 41, 174.20, 522.8, and 747.2, respectively; this gradual increase was statistically significant over the first 6 months (p = 0.004) but not between months 6 and 12 (p = 0.255). The trend towards an increasing number of active glands occurred in both groups, with a mean of 1369.8 active glands in group B compared to 747.2 (p = 0.095) in group A after 12 months. It is well-known that Cannon's law of denervation (1939) is not applicable to the sweat glands, that is, there is no hyperactivation following intradermal acetylcholine stimulation. However, some response, which increased over the first 6 months following surgery, was observed in our study. Nevertheless, this activation is subsequently self-limiting, resulting in no gland atrophy, and reinnervation occurs without patient awareness.

Effect of Thoracic Sympathectomy on Exercise Tolerance and Cardio- Pulmonary Responses to Exercise

PURPOSE: Sympathetic denervation may limit exercise performance capacity by reducing cardiac output and/or by negatively affecting skeletal muscle metabolic behavior. To test this hypothesis, we studied the effect of endoscopic thoracic sympathectomy (ETS) for palmar and/or axillary hyperhidrosis on physiological responses at rest, and during submaximal and maximal exercise in 10 healthy patients (7 females and 3 males 18-40 years old) with idiopathic palmar and/or axillary hyperhidrosis. METHODS: T2-T3 thoracoscopic sympathicolysis was performed using a simplified one stage bilateral procedure. Physiological variables were recorded at rest and during sub-maximal (steady-state) and maximal treadmill exercise before and 70 (±7.5, SD) days after bilateral ETS. RESULTS: Palmar and/or axillary hyperhidrosis was relieved in every patient, confirming the T2- T3 denervation. After bilateral ETS exercise performance capacity (peak work rate reached) and peak VO2 were not different than prior to the ETS. However, heart rate was significantly reduced at rest 14%), at sub-maximal exercise (12.3%) and at peak exercise (5.7%) together with a significant increase in oxygen pulse (11.8%, 12.7% and 7.8%, respectively).The rate Pressure Product (RPP) was also significantly reduced following the surgical procedure at all three study stages. All other physiological variables measured remained unchanged during the three study's stages. CONCLUSIONS: It is suggested that sympathetic denervation of the upper limb do not affect exercise performance or mechanical/physiologic efficiency despite a significant reduction in heart rate (at rest and during exercise) which was, most likely, fully compensated by an increase in stroke volume and/or by an improved muscle O2 extraction and/or utilization (as indicated by the increased O2pulse), keeping the cardiac output and oxygen uptake unaffected.

Anatomical redistribution of sweating after T2–T3 thoracoscopic sympathicolysis: a study of 210 patients

The cutaneous influence areas of the different sympathetic ganglia have not been fully established to date. The aim of this study was to define the cutaneous influence area of sympathetic ganglia T2-T3. A total of 210 patients with primary hyperhidrosis (PH) underwent 420 thoracoscopic sympathicolysis procedures of ganglia T2-T3 in a prospective study. All completed a preoperative questionnaire and a second questionnaire 12 months after the operation. The questionnaires evaluated perspiration in the different body areas. Only the zones of anhidrosis were considered in delimiting the cutaneous expression of sympathetic ganglia T2-T3. Redistribution of perspiration as reported by the patients comprised significant reduction in the palms, axillas, and soles, and an increase in the abdomen, back, and gluteal and popliteal regions. Regarding the incidence of anhidrosis by anatomical location, statistically significant changes were recorded in the head, hands, axillas, and soles (p < 0.001). Bilateral upper thoracic sympathicolysis is followed by redistribution of body perspiration, with a clear decrease in the zones regulated by mental or emotional stimuli, and an increase in the areas regulated by environmental stimuli, though we are unable to establish the etiology of this redistribution.

Volume and cellular content of normal pleural fluid in humans examined by pleural lavage.

Currently, no reliable data are available on the volume or on the cellular content of pleural fluid in normal humans. In analogy with bronchoalveolar lavage (a technique enabling retrieval of small volumes of epithelial lining fluid from the lung), we developed a pleural lavage (PL) technique consisting of injection and retrieval of 150 ml of saline into the right pleural space, performed during a thoracoscopic sympathicolysis procedure in otherwise healthy subjects suffering from essential hyperhidrosis. With urea used as an endogenous marker of dilution, measured mean right-sided pleural fluid volume was 8.4 +/- 4.3 ml. In a subgroup of subjects, we confirmed that right- and left-sided pleural fluid volumes were similar. Expressed per kilogram of body mass, total pleural fluid volume in normal, nonsmoking humans is 0.26 +/- 0.1 ml/kg. Total cell count in the PL fluid of nonsmoking normal subjects yielded a median of 91 x 10(3) white blood cells (WBC) per milliliter of lavage fluid (interquartile range [IR] = 124 x 10(3) cells/ml). Taking into account a measured dilution factor of 18.86, the total WBC count in the original pleural fluid was 1,716 x 10(3) cells/ml. Differential cell counts yielded a predominance of macrophages (median: 75%; IR: 16%) and lymphocytes (median: 23%; IR: 18%). Mesothelial cells (median: 1%; IR: 2%), neutrophils (median: 0%; IR: 1%), and eosinophils (median: 0%; IR: 0%) were only marginally present. There were no significant differences between males and females or between right- and left-sided pleural fluid in total and differential cell counts. In contrast, in smokers a small but statistically significant increase in pleural fluid neutrophils (median: 1%; IR: 2%; p < 0.015) was observed. In conclusion, PL performed during thoracoscopy for sympathicolysis allowed for the first time determination of the volume and of the total and differential cell contents of the pleural fluid present in normal human pleura.

Prolonged Paralysis After a Test Dose of Mivacurium in a Patient with Atypical Serum Cholinesterase

Prolonged Paralysis After a Test Dose of Mivacurium in a Patient with Atypical Serum Cholinesterase

Partial pulmonary sympathetic denervation by thoracoscopic D2–D3 sympathicolysis for essential hyperhidrosis: effect on the pulmonary diffusion capacity

In patients with essential hyperhidrosis (EH), a pathological condition characterized by increased activity of the upper dorsal sympathetic ganglia D 2–D 3, anatomical interruption at the D 2–D 3 level by thoracoscopic sympathicolysis (TS) is a safe and effective treatment. The D 2 and D 3 ganglia, however, are also in the pathway of sympathetic lung innervation, which may influence the pulmonary diffusion capacity for carbon monoxide (expressed as transfer factor for and as transfer coefficient for CO: KCO). We therefore studied the effect of TS on T lCO and KCO in 50 EH patients: compared with pre-operative values, both T lCO (−6·7%, P<0·001) and KCO (-4·2%, P=0·002) were significantly decreased at 6 weeks after bilateral TS, an effect which was independent of the smoking status of the patients. In order to explain this phenomenon, the following pharmacological interventions were studied: (1) oral β 1+2-adrenoreceptor blockade with propranolol caused a comparable decrease of T lCO (−6·3%) and KCO (−7·5%) in matched normal subjects, but had no effect on T lCO and KCO in EH patients prior to TS; and (2) subsequent inhalation of the β 2-adrenoreceptor agonist salbutamol in a dosage suspected to cause alveolar β-receptor stimulation had no effect on T lCO and KCO, neither in the normal subjects, nor in EH patients (before and after TS). Although the exact mechanism of the TS-induced decrease in T lCO and KCO remains speculative, these findings suggest that they may be related to a β 1-adrenoreceptor-mediated change in pulmonary capillary membrane permeability, although TS-induced changes in pulmonary blood flow or an interplay of both mechanisms cannot be excluded.

Effects of non-pharmacological sympathetic sudomotor denervation on sweating in humans with essential palmar hyperhidrosis

Objectives: Quantitative sweat production and -ionic composition in Essential Hyperhidrosis (EH), and the effects of T2T3 thoracoscopic sympathicolysis (TS) hereon, are unknown. Standardised pilocarpine iontophoresis sweat tests were performed before and after TS in order to study these issues. Design and Methods: Pilocarpine iontophoretic sweat tests measuring maximal sweat production (mg) and sweat Na +, K + and Cl − concentrations (mMol/l) were performed on both forearms of 10 EH patients, before and six weeks after TS, and in normal volunteers. Results: As compared to normals, preoperative maximal sweat production was 30% higher (199.4 ± 68.8 (SD) vs. 150.6 ± 45.6 mg) in EH patients; due to type II error, however, statistical significance was not reached. Na + and Cl − concentrations were similar, and K + concentration was slightly lower in EH patients. After TS, sweat production had decreased to equal levels as in normals (149.1 ± 52.1 mg), whereas the Na + (from 33.6 ± 6.9 to 51.0 ± 6.4 mMol/L), Cl − (from 21.5 ± 6.6 to 37.2 ± 7.1 mMol/L) and K + (from 7.5 ± 1.3 to 8.6 ± 2.2 mMol/L) concentrations had increased. Conclusions: EH patients present 30% higher maximal sweat production at their forearms. This increase may be due to an increased activity of the adrenergic component of sweat gland innervation. The post-TS increase in Na +, Cl − and K + concentrations suggests that the adrenergic component of sweat gland innervation in itself decreases sweat ion concentrations.

Changes in cardiocirculatory autonomic function after thoracoscopic upper dorsal sympathicolysis for essential hyperhidrosis

Essential hyperhidrosis (EH) is caused by an unexplained overactivity of the sympathetic fibers which pass through the upper dorsal sympathetic ganglia D2 and D3. Since the D2 and D3 ganglia are also involved in the sympathetic cardiac innervation, cardiocirculatory autonomic function may also be abnormal in EH. In order to study the function of the sympathetic nervous system in EH, and to assess the effects of thoracoscopic sympathicolysis, cardiocirculatory autonomic function tests were performed in 13 consecutive patients with EH, before (baseline) and 6 weeks after the thoracoscopic intervention. Baseline data were also compared with data obtained from 13 matched healthy volunteers: EH patients showed an increased heart rate at rest, but only in the standing position (94 ± 18.5 vs 78 ± 10.9 bpm, P < 0.01), as well as an increased ratio of low to high frequency power of the heart rate variability in the standing position (5.92 ± 4.4 vs 2.8 ± 2.5, P < 0.05). Exercise tests were normal in every EH patient. After sympathicolysis, heart rate at rest (sitting on the cycloergometer) had decreased (75.4 ± 13 vs 90.4 ± 16.5 bpm, P < 0.05), as well as heart rate at maximal exercise (165.2 ± 14.8 vs 180 ± 10 bpm, P < 0.05). Exercise capacity and the cardiorespiratory responses to exercise were, however, unchanged after sympathicolysis. Resting heart rate in the lying (66 ± 10 vs 76 ± 15 bpm, P < 0.05) and standing positions (82 ± 13.8 vs 94 ± 18.5 bpm, P < 0.05), and the diastolic blood pressure reaction to a handgrip test (73.6 ± 8.6 vs 84.7 ± 11.6 mmHg, P < 0.05) were also lowered after sympathicolysis. In conclusion, patients with EH show an overfunctioning of the sympathetic system which is characterised by an increased reaction to stress (standing, exercise), whereas resting sympathetic tone is unaffected. Thoracoscopic D2–D3 sympathicolysis corrects this hyperfunction and has a partial beta-blocker-like activity, which results in a decrease in heart rate at rest and during maximal exercise, and in the diastolic blood pressure response to the handgrip test. Further studies are needed to assess the long-term consequences of this procedure.

Thoracoscopic sympathicolysis for essential hyperhidrosis: effects on pulmonary function.

Bilateral interruption of the upper dorsal sympathetic chain at the D2 and D3 level represents the only permanent cure for essential hyperhidrosis. Following surgical sympathectomy, significant and symptomatic changes in pulmonary function have been observed. Since functional effects of the surgical intervention cannot be excluded, we wondered whether such alterations also occurred after thoracoscopic sympathicolysis; these should then be attributable to the surgical denervation itself. Pulmonary function tests (PFTs), including spirometry and body plethysmographic measurement of lung volumes and airway resistance and conductance, were compared before and 6 weeks after thoracoscopic sympathicolysis in 47 patients. In order to virtually exclude any effects of thoracoscopy on the test results PFTs were repeated 6 months after thoracoscopic sympathicolysis in 35 patients. Essential hyperhidrosis was completely relieved in all patients, thereby confirming the interruption of the D2-D3 sympathetic chain. None of the patients developed respiratory symptoms after thoracoscopic sympathicolysis. Forced expiratory volume in one second (FEV1) (-3%), forced expiratory flow after exhaling 75% of vital capacity (FEF75) (-8%) and total lung capacity (TLC) (-3%) were slightly but significantly reduced at six weeks after thoracoscopic sympathicolysis; whereas airway resistance (Raw) had increased (+12%). After correction for the small decrease in lung volume (FEV1/forced vital capacity (FVC), specific airway resistance (sRaw), specific airway conductance (sGaw))significant changes in "volume-dependent" PFT parameters were no longer observed. Smoking status had no influence on the reduction in FEF75. At 6 months after thoracoscopic sympathicolysis, TLC had returned to preoperative values, whereas FEF75 remained decreased (-8.6%). The decrease in airway calibre was confirmed by small but significant changes in FEV1/FVC (-2%) and Raw (+29%). We conclude that thoracoscopic sympathicolysis in patients with essential hyperhidrosis causes only minimal and subclinical changes in pulmonary function secondary to a temporary small decrease in lung volume, which in turn is probably inherent to the thoracoscopic procedure. D2-D3 sympathicolysis, in itself, is responsible only for a small and permanent decrease in forced expiratory flow, which suggests that, at least in essential hyperhidrosis patients, airway bronchomotor tone is influenced by sympathetic innervation.

A simplified T2-T3 thoracoscopic sympathicolysis technique for the treatment of essential hyperhidrosis: short-term results in 100 patients.

A simplified one-time bilateral thoracoscopic T2-T3 sympathicolysis technique using single-lumen endotracheal intubation with high frequency jet ventilation and electrocautery destruction ("sympathicolysis") of the sympathetic ganglia was applied in 100 consecutive patients with severe essential hyperhidrosis (EH). Providing a pleural space can be created, this technique was proven simple and safe, and short-term clinical results were excellent: palmar hyperhidrosis was cured in 98% of patients, and axillar and plantar improvement was achieved in 62 and 65% of patients, respectively. Side-effects and complications were minor (compensatory hyperhidrosis) or self-limiting (pain). These data confirm the safety and efficacy of thoracoscopic sympathetic interventions for the treatment of EH, and support the evolution toward simplified methodologies.

Thoracoscopic sympathicolysis for essential hyperhidrosis: immediate and one year follow-up results in 35 patients and review of the literature.

Various treatments for essential hyperhidrosis are available. The aim of this study is to present our experience with a simplified thoracoscopic sympathicolysis technique in this disorder, and to confront our results with data in the literature, 35 consecutive patients (11 male, 24 female, age 12-44 years) with essential hyperhidrosis, refractory to "conventional" medical treatment presenting between August 1993 and May 1994 were studied. Bilateral D2-D3 sympathicolysis was performed using a simplified one-time bilateral thoracoscopic procedure under general anaesthesia. Clinical scores, complications and side effects were recorded one week, one month and one year after the intervention. Severe hyperhidrosis was present in the hands in 100%, axillae in 66% and soles of the feet in 86% of patients. In one patient, only a unilateral intervention was possible due to pleural adhesions. In the other 34 patients, palmar hyperhidrosis was completely and permanently relieved in 100% of cases. Axillar hyperhidrosis was significantly improved after one year in 91% of patients, 52% of which showed a complete disappearance of hyperhidrosis. Side effects and complications were minimal. There were no permanent pleural, neurological (Horner) or other sequellae. Patient satisfaction was invariably very high. These findings compare favourably with historical data in the literature.