- Email: [email protected]
Reoperative Endoscopic Sympathectomy for Persistent or Recurrent Palmar Hyperhidrosis
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Reoperative Endoscopic Sympathectomy for Persistent or Recurrent Palmar Hyperhidrosis Richard K. Freeman, MD, Jaclyn M. Van Woerkom, RN, BSN, Amy Vyverberg, RN, BSN, and Anthony J. Ascioti, MD Department of Thoracic and Cardiovascular Surgery, St Vincent Hospital, Indianapolis, Indiana
Background. Sympathectomy for severe palmar hyperhidrosis occasionally fails. This investigation reviews our experience with reoperative thoracoscopic sympathectomy (RS) for patients with persistent or recurrent palmar hyperhidrosis after sympathectomy. Methods. A retrospective analysis of patients undergoing RS for palmar hyperhidrosis was conducted. Comparison was made with all patients undergoing an initial thoracoscopic sympathectomy (TS) for palmar hyperhidrosis at our institution during the same period. Results. Over 6 years, 40 patients underwent bilateral (32) or unilateral (8) RS for refractory (35) or recurrent (5) palmar hyperhidrosis. During the same period, 321 patients underwent bilateral TS for palmar hyperhidrosis. Previous methods of sympathectomy included percutaneous ablation (25), TS (10), axillary thoracotomy (3), and a posterior transthoracic approach (2). Twenty-two RS patients and 11 TS patients required a third port to complete the procedure because of pleural adhesions (p ⴝ 0.0001). Twenty-three RS and 11 TS
patients required postoperative pleural drainage (p ⴝ 0.0004). Mean length of stay was1.6 for the RS group and less than 1 day for the TS group (p ⴝ 0.0001). Alleviation of palmar hyperhidrosis occurred in 38 RS patients and 316 TS patients (p ⴝ 0.18). Compensatory sweating was identified in 21 RS patients and 101 TS patients (p ⴝ 0.01). Conclusions. Reoperative thoracoscopic sympathectomy produced a rate of improvement comparable to that of TS. However, RS was associated with an increased need for postoperative pleural drainage, longer hospital stay, a more difficult operative procedure, and a higher rate of compensatory sweating than TS was. Reoperative sympathectomy should be considered a safe and effective option for patients with palmar hyperhidrosis who remain severely symptomatic after a sympathectomy.
T
Material and Methods
horacoscopic sympathectomy has been proven to be a safe and effective technique for the treatment of primary palmar hyperhidrosis refractory to medical management [1–3]. As the utility of sympathectomy for this condition has been realized, patients are occasionally encountered whose hyperhidrosis either fails to improve or recurs after an initial sympathectomy by various techniques. Surgeons may be reluctant to offer further intervention to these patients because of a lack of experience with reoperative sympathectomy, the inability to predict the efficacy of such a procedure, or the lack of desire to treat a patient whose expectations have already not been met by the care of what is often another physician. This investigation reviews our experience with reoperative sympathectomy for patients with persistent or recurrent primary palmar hyperhidrosis after various forms of sympathectomy.
Accepted for publication March 25, 2009. Presented at the Fifty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Austin, TX, Nov 5– 8, 2008. Address correspondence to Dr Freeman, 8433 Harcourt Rd, Indianapolis, IN 46260; e-mail: [email protected].
© 2009 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2009;88:412–7) © 2009 by The Society of Thoracic Surgeons
A retrospective analysis of all patients undergoing thoracoscopic sympathectomy in our practice over a 6-year period for persistent or recurrent primary palmar hyperhidrosis after a previous sympathectomy was performed. Our Institutional Review Board approved this investigation and waived individual patient consent. Demographic information, procedural details and morbidities were extracted from inpatient and outpatient records. The degree of symptoms of each patient as well as evidence of significant compensatory sweating was assessed before and 2 months after sympathectomy using the Hyperhidrosis Disease Severity Scale (Table 1) and the compensatory sweating categories developed in our practice (Table 2), respectively [4]. For the purposes of this investigation, significant compensatory sweating was defined as level 3 or 4 symptoms. Outcomes of patients undergoing reoperative sympathectomy were compared with those of all patients undergoing thoracoscopic sympathectomy for primary palmar hyperhidrosis in our practice during the same time period. Excluded from participation in this investigation were patients undergoing initial or reoperative sympathectomy for conditions other than primary palmar hyperhidrosis, patients who had not undergone an adequate trial of 0003-4975/09/$36.00 doi:10.1016/j.athoracsur.2009.03.101
FREEMAN ET AL REOPERATIVE SYMPATHECTOMY FOR PALMAR HYPERHIDROSIS
Table 1. Hyperhidrosis Disease Severity Score Class 1 2 3 4
Table 3. Methods of Previous Sympathectomy
Severity
Method
Number
Never interferes or is noticeable Tolerable, sometimes interferes Barely tolerable, frequently interferes Intolerable and always interferes
Endoscopic Percutaneous ablation Axillary thoracotomy Posterior approach
10 25 3 2
medical therapy for primary palmar hyperhidrosis, patients who did not have a level of symptoms that interfered with their activities of daily living (class 3 or 4 symptoms on the Hyperhidrosis Disease Severity Scale), and patients who did not return for evaluation after surgery. Analysis of data was carried out using GraphPad Prism software 4.02 (San Diego, CA) for Windows (Microsoft, Redmond, WA). Continuous data are expressed as the mean ⫾ SD of the mean except where otherwise indicated. Differences between categorical variables were evaluated by the Fisher’s exact test. Differences between continuous variables were measured by the two-tailed Student t test. A value of p less than 0.05 was considered significant.
Operative Technique General anesthesia was utilized for all subjects in this investigation. Neither central venous access nor intraarterial blood pressure monitoring was performed. A single-lumen endotracheal tube was utilized and contralateral, single-lung ventilation established with the use of an Arndt bronchial blocker (Cook Medical, Bloomington, IN). All patients were positioned in a semi-sitting position with the arms elevated above the head. The neck, chest, and abdomen were included in the operative field. Patients undergoing an initial thoracoscopic sympathectomy had a 5-mm thoracoscopic port placed in the anterior axillary line of the fifth intercostal space and the midclavicular line of the seventh intercostal space bilaterally after the skin and subcutaneous tissues had been infiltrated with local anesthetic. Mild CO2 insufflation was initiated. The 5-mm thoracoscope and a hook electrocautery instrument were used to incise the pleura overlying the sympathetic chain. The third thoracic sympathetic ganglion was then excised between the third and fourth ribs. A red rubber catheter was placed through the inferior port to the apex of the pleural space and placed to underwater seal. The lung was reexpanded. Once all air had been evacuated from the chest, the incisions were closed by approximating the skin with absorbable suture. If there was a persistent air leak from an injury to the Table 2. Compensatory Sweating Levels Level 1 2 3 4
413
Symptoms None Rare and mild Daily and moderate Severe
visceral pleura, a 10F pleural catheter brought out through the most lateral port incision and was left in place for 12 to 14 hours. The procedure was then repeated on the contralateral side. Patients who did not require a pleural drain were discharged home the afternoon of surgery. Patients who required a pleural drain or failed to meet discharge criteria were admitted overnight and discharged the next morning. Patients undergoing reoperative sympathectomy were similarly positioned and had the same initial port placements as described. Contralateral single lung ventilation and CO2 insufflation were also used. If there were extensive pleural adhesions, a third 5-mm port was placed to facilitate retraction of the lung. These patients also underwent the excision of the third thoracic sympathetic ganglion. The evacuation of pleural air, pleural drainage, and discharge intentions were the same as described for patients undergoing initial sympathectomy.
Results Over a 72-month period, 40 patients underwent bilateral (32) or unilateral (8) reoperative thoracoscopic sympathectomy for refractory (35) or recurrent (5) primary palmar hyperhidrosis. Previous methods of sympathectomy are displayed in Table 3. Of the patients undergoing a reoperative procedures, 2 had their original operative sympathectomy performed by one of the authors. All of the percutaneous ablations were thermal ablations that were intended to ablate the third thoracic sympathetic ganglion. None of these was performed by the authors. During the same period, 333 patients underwent a bilateral thoracoscopic sympathectomy for primary palmar hyperhidrosis. Of these, 321 met the inclusion criteria of this study and were analyzed. A comparison of patient demographics is seen in Table 4. Mean time from initial to reoperative sympathectomy in the reoperative patient group was 27 months and did not differ significantly between patients undergoing an initial operative or ablative sympathectomy. Operative time compared as unilateral sympathectomy was not significantly different between the two groups despite reoperative sympathectomy patients requiring the addition of a third unilateral port and or a postoperative pleural drain significantly more frequently than initial sympathectomy patients. However, the difference in the operative times between patients undergoing reoperative sympathectomy after a percutaneous ablative technique versus an operative approach nearly attained statistical significance in subset analysis (p ⫽ 0.051) reflecting the pleural adhesions encountered in each type of patient.
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Table 4. Comparison of Two Treatment Groups’ Characteristics and Outcomes
Number Unilateral Bilateral Age (mean years) Operative timea (mean min) Third trochar Pleural drain Hospital stay (mean days) Follow-up complete Symptom improvementb Compensatory sweatingc a
Measured as unilateral procedure time.
b
Initial Sympathectomy
Reoperative Sympathectomy
321 8 321 21 14 11 11 ⬍1 100% 316 (98%) 101 (31%)
40 32 27 26 22 23 1.6 100% 38 (95%) 21 (53%)
Defined as a reduction in severity to class 1 or 2 symptoms.
An attempt was made to assign a reason for failure of the original sympathectomy in each case at the time of reoperation. Despite the initial technique of sympathectomy, failure was attributable to inaccurate localization (31) or incomplete resection (7) of the sympathetic ganglion in 38 of the reoperative patients. The etiology did not vary significantly between the operative or ablative group. Thirty of 31 inaccurate localizations (97%) occurred in percutaneous ablation or thoracotomy patients, whereas this cause was identified in only 1 failure of a thoracoscopic sympathectomy. No cause for failure could be reliably assigned in 2 patients who had undergone a prior endoscopic sympathetic clip application except for the possibility of incomplete clip application by the original surgeon. A significant difference was also seen between the two patient groups related to length of stay. This was attributable exclusively to the placement of a pleural drain in reoperative patients. No patient in either group required longer than an overnight hospital stay after sympathectomy. There was not a mortality in either group of patients. There were no significant differences in the incidence of morbidity between the two groups (Table 5). No patient in either group required reoperation for bleeding or experienced a Horner’s syndrome. All 40 patients undergoing reoperative sympathectomy and 321 patients undergoing initial sympathectomy returned for their postoperative outpatient assessment. There were equal rates of symptom improvement between the two groups, defined as a reduction to class 1 or 2 symptoms on the Hyperhidrosis Disease Severity Scale. There was, however, a significant difference in patients who realized significant compensatory sweating after
c
p Value
0.053 0.0003 0.0004 0.0001 0.18 0.01 Defined as level 3 or 4 symptoms.
reoperative sympathectomy when compared with initial sympathectomy patients. No patients in either series required operative reversal of their sympathectomy for compensatory sweating. Two patients who underwent reoperative sympathectomy and 5 patients undergoing initial sympathectomy did require medical treatment of their compensatory sweating (p ⫽ 0.17).
Comment Sympathectomy as a treatment for severe hyperhidrosis is not a new concept. Although Alexander is credited with performing the first cervicothoracic sympathectomy in 1889, the first reported sympathectomy for hyperhidrosis is attributed to Kotzareff and reported in 1920 [5, 6]. Subsequently, dorsal, supraclavicular, and multiple thoracotomy approaches were developed in an attempt to minimize the patient’s experience for a benign disease [7–9]. Endoscopic sympathectomy was not reported until 1951 by Kux [10]. He went on to develop a standardized technique for the procedure accomplished using intrathoracic insufflation without endotracheal intubation. However, despite the excellent results achieved by Kux [11] in a subsequent report of 55 patients with palmar and axillary hyperhidrosis, widespread interest and adoption of endoscopic sympathectomy awaited the advances in fiberoptic technologies and instrumentation that ushered in the modern era of endoscopic surgery. Throughout the 1990s, the technique of endoscopic sympathectomy was enhanced until it had replaced all of the other techniques for thoracic sympathectomy for hyperhidrosis except one: percutaneous ablation. First reported in 1984 as a treatment for hyperhidrosis, this
Table 5. Morbidities
Pneumothorax Wound infection Pleural effusion Incision hyperesthesias
Initial Sympathectomy
Reoperative Sympathectomy
p Value
4 (1%) 6 (2%) 7 (2%) 3 (0.9%)
1 (3%) 2 (5%) 2 (5%) 1 (3%)
0.44 0.21 0.26 0.37
FREEMAN ET AL REOPERATIVE SYMPATHECTOMY FOR PALMAR HYPERHIDROSIS
Fig 1. Thoracoscopic view of pleural adhesions after a percutaneous thermal ablation.
technique utilized radiofrequency ablation, thermal coagulation, or chemical ablation to destroy a segment of the sympathetic chain with or without image guidance [12]. Proponents of the procedure, often neurosurgeons, saw the ability to offer it to their patients without the need for general anesthesia or a thoracic surgical procedure. However, the lack of direct visualization of the sympathetic chain led to rates of recurrence of symptoms and Horner’s syndrome that should be considered unacceptable when compared with the endoscopic technique in experienced hands [13]. As endoscopic sympathectomy and, to a lesser extent, percutaneous ablation have been used in increasing frequency over the last 20 years to treat primary palmar hyperhidrosis, some patients have not experienced an improvement in their symptoms. These patients can be segregated into those whose symptoms improved or completely resolve only to recur and those whose symptoms persisted after surgery. Rates of failure for endoscopic sympathectomy since 1999 have ranged between 1% and 4%, and persistence or recurrence of symptoms for percutaneous ablative techniques has been reported as high as 16% [13, 14]. While there is a paucity of literature describing the treatment of patients whose symptoms persist or recur after percutaneous ablative sympathectomy, four reports of reoperative endoscopic sympathectomy do exist. Orteu and colleagues [15] and Sing and coworkers [16] separately published case reports of patients who required reoperative sympathectomy for hyperhidrosis in 1995 and 1998, respectively. Hsu and coworkers [17] were the first to publish a series of patients requiring reoperative sympathectomy for palmar or axillary hyperhidrosis in 1998. All 20 of these patients had undergone previous endoscopic sympathectomy, with 19, or 95%, realizing relief of their symptoms after reoperation. The overwhelming reason for failure of the initial sympathectomy in these patients according to the authors was an inadequate or inaccurate initial sympathectomy.
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Lin and colleagues [18] subsequently published what remains the largest series of patients undergoing reoperative sympathectomy for persistent or recurrent palmar hyperhidrosis. All of these patients had undergone an initial endoscopic sympathectomy. The authors reported that all patients in this series experienced resolution of their hyperhidrosis after reoperative sympathectomy but experienced an 86% incidence of compensatory sweating. This investigation also demonstrates the effectiveness of reoperative sympathectomy for patients experiencing persistent or recurrent primary palmar hyperhidrosis after a previous sympathectomy. However, unlike the previously discussed reports, the methods of initial sympathectomy in this series were diverse and included axillary and posterior thoracotomies as well as a large number of patients who underwent percutaneous ablation. The results of reoperative sympathectomy in these patients have not been previously reported. These different techniques produced varying degrees of pleural adhesions, which were not predictable based on the original form of sympathectomy and which accounted for the significant differences in pleural drainage and length of stay between the two patient groups. In fact, the authors observed some of the most dense and widespread adhesions in patients who had undergone a percutaneous ablation as their initial procedure (Fig 1). However, the technique of initial sympathectomy did result in technique specific reasons for failure. Inaccurate localization accounted for all of the failures of patients undergoing percutaneous ablation and alternative forms of thoracotomy, and incomplete resection of the sympathetic ganglion remained the common finding in patients who had previously undergone an endoscopic sympathectomy (Fig 2). These findings are intuitive, understanding that the percutaneous technique uses external landmarks to localize the area of the sympathetic chain, and that the two forms of thoracotomy used generally provide poor exposure to this area, especially on the right. Endoscopic sympathectomy provides excellent vi-
Fig 2. Incomplete clip occlusion of the sympathetic ganglia.
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sualization of the sympathetic chain, with failures in these patients resulting almost exclusively failing to provide a complete form of sympathectomy. Despite these differences, this investigation found that the effectiveness of reoperative endoscopic sympathectomy remained high while morbidity and length of stay were acceptable. Compensatory sweating, however, was significantly more common in the reoperative group despite attempting to perform the same resection as patients undergoing initial sympathectomy received. While it is unclear why this should be observed, it is most likely because of the effects of a second procedure, which may have produced an effect similar to a more extensive sympathectomy. Although this investigation reports the largest group of patients in the literature undergoing reoperative endoscopic sympathectomy after various initial procedures, some weaknesses do exist in its design. As in any unusual condition, the absolute number of patients in this study remains small. Also, although all patients included were considered to have failed medical therapy, patients were not randomly assigned to a nonsurgical treatment. The author’s standard follow-up scheme was also utilized for all of the patients in this review. Rates of compensatory sweating in both patient groups and rates of recurrence in patients undergoing an initial sympathectomy might benefit from a longer period of postoperative observation. In conclusion, this investigation found that, despite widely disparate techniques of initial sympathectomy for primary palmar hyperhidrosis, reoperative endoscopic sympathectomy is highly effective for patients who have persistent or recurrent symptoms. Reoperative sympathectomy is likely to encounter varying degrees of pleural adhesions, resulting in the increased need for postoperative pleural drainage and hospital admission. The incidence of significant compensatory sweating is also increased among patients undergoing reoperative sympathectomy. With these factors involved in the informed consent process, reoperative endoscopic sympathectomy should be offered by surgeons experienced in the technique to patients with severe persistent or recurrent symptoms of primary palmar hyperhidrosis after an unsuccessful sympathectomy, regardless of the initial technique used.
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References 1. Miller DL, Force SD. Outpatient microthoracoscopic sympathectomy for palmar hyperhidrosis. Ann Thorac Surg 2007; 83:1850 –3. 2. Kwong KF, Cooper LB, Bennett LA, Burrows W, Gamliel Z, Krasna MJ. Clinical experience in 397 consecutive thoracoscopic sympathectomies. Ann Thorac Surg 2005;80:1063– 6. 3. Doolabh N, Horswell S, Williams M, et al. Thoracoscopic sympathectomy for hyperhidrosis: indications and results. Ann Thorac Surg 2004;77:410 – 4. 4. Strutton DR, Kowalski JW, Glaser DA, et al. US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol 2004;51:241– 8. 5. Drott C. The history of cervicothoracic sympathectomy. Eur J Surg 1994;572(Suppl):5. 6. Kotzareff A. [Resection partielle du tronc droit du grand sympathique cervical pour hyperdrose unilateral de meme cote.] Rev Med Suisse Romande 1920;40:111–3. 7. Adson AW. Changes in technique of cervicothoracic ganglionectomy and trunk resection. Am J Surg 1931;23:287– 8. 8. Teleford ED. The technique of sympathectomy. Br J Surg 1935;23:448 –50. 9. Atkins HJB. Sympathectomy by the axillary approach. Lancet 1954;1:538 –9. 10. Kux E. The endoscopic approach to the vegetative nervous system and its therapeutic possibilities. Dis Chest 1951;20: 13– 47. 11. Kux M. Thoracic endoscopic sympathectomy in palmar and axillary hyperhidrosis. Arch Surg 1978;113:264 – 6. 12. Wilkinson HA. Percutaneous radiofrequency upper thoracic sympathectomy: a new technique. Neurosurgery 1984;15: 11– 4. 13. Chuang KS, Liu JC. Long-term assessment of percutaneous stereotactic thermocoagulation of upper thoracic ganglionectomy and sympathectomy for palmar and craniofacial hyperhidrosis in 1742 cases. Neurosurgery 2002;51:963–9. 14. Dumont P. Side effects and complications of surgery for hyperhidrosis. Thorac Surg Clin 2008;18:193–207. 15. Orteu CH, McGregor JM, Almeyda JR, Rustin MHA. Recurrence of hyperhidrosis after endoscopic transthoracic sympathectomy: case report and review of the literature. Clin Exp Dermatol 1995;20:230 –3. 16. Singh B, Moodley J, Haffejee AA, Ramdial PK, Robbs JV, Rajaruthnam P. Resympathectomy for sympathetic regeneration. Surg Laparosc Endosc 1998;8:257– 60. 17. Hsu CP, Chen CY, Hsia JY, Shai SE. Resympathectomy for palmar and axillary hyperhidrosis. Br J Surg 1998;85:1504 –5. 18. Lin TS. Video-assisted thoracoscopic resympathectomy for palmar hyperhidrosis. Analysis of 42 cases. Ann Thorac Surg 2001;72:895– 8.
DISCUSSION DR MARK J. KRASNA (Towson, MD): Doctor Reed, Dr Meyers, members and guests. I want to thank Dr Freeman and his colleagues for providing me with the manuscript and congratulate him on an excellent presentation. Thoracoscopic sympathectomy is a safe, simple and straightforward operation performed for many different indications, primarily done in this country for hyperhidrosis, a socially debilitating condition that affects almost 1% of the population worldwide. Despite the fact that there is a straightforward operation described to treat this condition, there is much controversy about the indications and the preferred surgical technique for performing sympathectomy. This is evidenced by the high proportion of malpractice cases in the United States that relate to this procedure currently.
This presentation describes a subgroup of patients rarely discussed in the thoracic literature, that is, patients who have suffered from a failed sympathectomy after either a previous thoracic surgical procedure or a previous percutaneous nerve ablation intervention. During this 6-year period, 40 patients of a total of almost 360 patients at their facility had surgery for repeat sympathectomy; 25 of these were for percutaneous ablation and 15 for prior sympathectomy. The authors have found that the redo sympathectomy was feasible with only minor additional morbidity, minor additional operating room time, and slightly longer duration of chest tube drainage. The success rates were the same among both groups, although the incidence of compensatory sweating was significantly worse in the redo group. I have three questions for Dr Freeman.
FREEMAN ET AL REOPERATIVE SYMPATHECTOMY FOR PALMAR HYPERHIDROSIS
First, you note that the patients were assessed before and 2 months after sympathectomy. Our practice has been to follow up with patients either in person or by letter at least 2 more times during the postoperative period to assure that the patients complete their questionnaires at least one time during the summer season. Have you done this, or do you know the seasonal variation of your postoperative visits? Obviously, patients who are being followed up in Indiana in the wintertime may give better than average results. Second, do you think that there is a difference between the two treatment groups, namely, those who had prior surgical sympathectomy versus those who had a percutaneous ablation? I know the numbers would be small, but have you had a chance to look at the subgroups and compare the differences in success rate among them? Finally, one question regarding your technique. You describe the anesthesia technique as using a bronchial blocker. Does this mean that the patient was first bronchoscoped to place the blocker on one side and then rescoped to place the blocker on the other side, or did you just use the CO2 and only drop one lung? And then, again, on the surgical technique side, you describe excising the sympathetic ganglia. That is something that has rarely been described recently in the thoracic literature. Has your group tried in the past either cutting, ablating, or clipping the nerve above and below the ganglion rather than actually excising it? Again, I want to thank the Association for the privilege of discussing the paper, and I congratulate you and your authors for a well-written manuscript and a well-presented series. DR FREEMAN: Thank you, Dr Krasna. It is a pleasure to have you review our paper in light of your contributions to this subject, and I will answer your questions in order. To be honest with you, we have not really considered when we do our follow-ups. In my practice, when I look at my office, these are the highest rate of no-show patients, both for new consultation and for follow-up, to the point that I have had to limit the number of these patients that I will see in one day because of the cancellations. We have a bimodal distribution, winter break, summer, because of the age of the patients. So most of the patients are operated on in the summer, and most of them still get their follow-up in the time when it is still warm, but that is a very good point. Looking at the subpopulations, there is a very large difference in our small experience between patients who have had surgery and patients who had an ablation. The patients who had an ablation, they didn’t get close to the sympathetic ganglion was the bottom line. So when we go in there, there are a lot of adhesions, you take that down, and then it is a straightforward surgery. The patients who had had prior surgical sympathectomy were a mixed bag; some had clips, some had the wrong ganglion worked on, et cetera, et cetera. So really, in the ablation patients, they just missed the sympathetic ganglia. As far as the blocker, we use the bronchial blocker for almost all our procedures that we need, contralateral, single lung, ventilation, all except lung transplant, and have been very happy with it. The anesthesiologist places it on one side. We gently insufflate some CO2. As soon as we are done, they are repositioning the blocker while we are evacuating air before we move to the next side.
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DR ROBERT J. CERFOLIO (Birmingham, AL): Congratulations. I think we have a unique opportunity here with all the experts in the room to answer some questions that I don’t think we know the answer to. Now, you showed that 10 people had clips and failed. Is anybody in the room using clips routinely? Nobody. Clips only. Has anybody taken a clip off to treat compensatory hyperhidrosis, which is the reason people went to clips in the first place? Have you? DR FREEMAN: No, I don’t clip. DR CERFOLIO: Does it work or is the nerve dead? So the advantage of the clip was to treat compensatory hyperhidrosis. I am unsure of the data that it does reverse compensatory hyperhidrosis, but I have heard personal reports from some that it does. Until we have data that it does, and since the failure rate may be higher with clipping instead of cutting the nerve, should we be clipping? DR FREEMAN: Almost everybody in my office has been on the Internet and they say, do you clip? DR CERFOLIO: Right, I get the same question, but can we get something out there now with data and all the world’s experts here, or at least southern experts, that we should or shouldn’t be clipping? DR FREEMAN: In my opinion, yes, because if the hyperhidrosis goes away, it means the nerve is dead. DR CERFOLIO: Right, I am agreeing with you, but I want to hear that from a group of experts. DR KRASNA: Just a comment. There are no prospective randomized data in the literature that will show that clipping is better in any way than sympathectomy or sympathecotomy. I think what you have pointed out, though, is, for whatever reason, in your practice the majority of failures were among clips. But I don’t know that we can say quite what you said yet, Cerf. DR DANIEL L. MILLER (Atlanta, GA): Could you tell us briefly about the percutaneous ablation technique and the patients who failed treatment? DR FREEMAN: The percutaneous patients who failed? DR MILLER: No, the patients who had undergone a redo procedure. Why did they fail? Was it a wrong level? Did they miss the nerve? Was an accessory nerve still intact? More details would be greatly appreciated. Thank you. DR FREEMAN: In general, there are three percutaneous techniques: thermal, radiofrequency, or chemical. There has been a large series reported from China, and in this country, neurosurgeons are very much a proponent of this because they can offer that and they can’t offer the other thing. So I came after a neurosurgeon who did a bunch of these, and that is why we have those in our practice. They failed because they just didn’t get to the right spot in our series. I don’t have the denominator, so I can’t tell you how many of them worked. But that is why they failed in our series.
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Reoperative Endoscopic Sympathectomy for Persistent or Recurrent Palmar Hyperhidrosis Richard K. Freeman, MD, Jaclyn M. Van Woerkom, RN, BSN, Amy Vyverberg, RN, BSN, and Anthony J. Ascioti, MD Department of Thoracic and Cardiovascular Surgery, St Vincent Hospital, Indianapolis, Indiana
Background. Sympathectomy for severe palmar hyperhidrosis occasionally fails. This investigation reviews our experience with reoperative thoracoscopic sympathectomy (RS) for patients with persistent or recurrent palmar hyperhidrosis after sympathectomy. Methods. A retrospective analysis of patients undergoing RS for palmar hyperhidrosis was conducted. Comparison was made with all patients undergoing an initial thoracoscopic sympathectomy (TS) for palmar hyperhidrosis at our institution during the same period. Results. Over 6 years, 40 patients underwent bilateral (32) or unilateral (8) RS for refractory (35) or recurrent (5) palmar hyperhidrosis. During the same period, 321 patients underwent bilateral TS for palmar hyperhidrosis. Previous methods of sympathectomy included percutaneous ablation (25), TS (10), axillary thoracotomy (3), and a posterior transthoracic approach (2). Twenty-two RS patients and 11 TS patients required a third port to complete the procedure because of pleural adhesions (p ⴝ 0.0001). Twenty-three RS and 11 TS
patients required postoperative pleural drainage (p ⴝ 0.0004). Mean length of stay was1.6 for the RS group and less than 1 day for the TS group (p ⴝ 0.0001). Alleviation of palmar hyperhidrosis occurred in 38 RS patients and 316 TS patients (p ⴝ 0.18). Compensatory sweating was identified in 21 RS patients and 101 TS patients (p ⴝ 0.01). Conclusions. Reoperative thoracoscopic sympathectomy produced a rate of improvement comparable to that of TS. However, RS was associated with an increased need for postoperative pleural drainage, longer hospital stay, a more difficult operative procedure, and a higher rate of compensatory sweating than TS was. Reoperative sympathectomy should be considered a safe and effective option for patients with palmar hyperhidrosis who remain severely symptomatic after a sympathectomy.
T
Material and Methods
horacoscopic sympathectomy has been proven to be a safe and effective technique for the treatment of primary palmar hyperhidrosis refractory to medical management [1–3]. As the utility of sympathectomy for this condition has been realized, patients are occasionally encountered whose hyperhidrosis either fails to improve or recurs after an initial sympathectomy by various techniques. Surgeons may be reluctant to offer further intervention to these patients because of a lack of experience with reoperative sympathectomy, the inability to predict the efficacy of such a procedure, or the lack of desire to treat a patient whose expectations have already not been met by the care of what is often another physician. This investigation reviews our experience with reoperative sympathectomy for patients with persistent or recurrent primary palmar hyperhidrosis after various forms of sympathectomy.
Accepted for publication March 25, 2009. Presented at the Fifty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Austin, TX, Nov 5– 8, 2008. Address correspondence to Dr Freeman, 8433 Harcourt Rd, Indianapolis, IN 46260; e-mail: [email protected].
© 2009 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2009;88:412–7) © 2009 by The Society of Thoracic Surgeons
A retrospective analysis of all patients undergoing thoracoscopic sympathectomy in our practice over a 6-year period for persistent or recurrent primary palmar hyperhidrosis after a previous sympathectomy was performed. Our Institutional Review Board approved this investigation and waived individual patient consent. Demographic information, procedural details and morbidities were extracted from inpatient and outpatient records. The degree of symptoms of each patient as well as evidence of significant compensatory sweating was assessed before and 2 months after sympathectomy using the Hyperhidrosis Disease Severity Scale (Table 1) and the compensatory sweating categories developed in our practice (Table 2), respectively [4]. For the purposes of this investigation, significant compensatory sweating was defined as level 3 or 4 symptoms. Outcomes of patients undergoing reoperative sympathectomy were compared with those of all patients undergoing thoracoscopic sympathectomy for primary palmar hyperhidrosis in our practice during the same time period. Excluded from participation in this investigation were patients undergoing initial or reoperative sympathectomy for conditions other than primary palmar hyperhidrosis, patients who had not undergone an adequate trial of 0003-4975/09/$36.00 doi:10.1016/j.athoracsur.2009.03.101
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Table 1. Hyperhidrosis Disease Severity Score Class 1 2 3 4
Table 3. Methods of Previous Sympathectomy
Severity
Method
Number
Never interferes or is noticeable Tolerable, sometimes interferes Barely tolerable, frequently interferes Intolerable and always interferes
Endoscopic Percutaneous ablation Axillary thoracotomy Posterior approach
10 25 3 2
medical therapy for primary palmar hyperhidrosis, patients who did not have a level of symptoms that interfered with their activities of daily living (class 3 or 4 symptoms on the Hyperhidrosis Disease Severity Scale), and patients who did not return for evaluation after surgery. Analysis of data was carried out using GraphPad Prism software 4.02 (San Diego, CA) for Windows (Microsoft, Redmond, WA). Continuous data are expressed as the mean ⫾ SD of the mean except where otherwise indicated. Differences between categorical variables were evaluated by the Fisher’s exact test. Differences between continuous variables were measured by the two-tailed Student t test. A value of p less than 0.05 was considered significant.
Operative Technique General anesthesia was utilized for all subjects in this investigation. Neither central venous access nor intraarterial blood pressure monitoring was performed. A single-lumen endotracheal tube was utilized and contralateral, single-lung ventilation established with the use of an Arndt bronchial blocker (Cook Medical, Bloomington, IN). All patients were positioned in a semi-sitting position with the arms elevated above the head. The neck, chest, and abdomen were included in the operative field. Patients undergoing an initial thoracoscopic sympathectomy had a 5-mm thoracoscopic port placed in the anterior axillary line of the fifth intercostal space and the midclavicular line of the seventh intercostal space bilaterally after the skin and subcutaneous tissues had been infiltrated with local anesthetic. Mild CO2 insufflation was initiated. The 5-mm thoracoscope and a hook electrocautery instrument were used to incise the pleura overlying the sympathetic chain. The third thoracic sympathetic ganglion was then excised between the third and fourth ribs. A red rubber catheter was placed through the inferior port to the apex of the pleural space and placed to underwater seal. The lung was reexpanded. Once all air had been evacuated from the chest, the incisions were closed by approximating the skin with absorbable suture. If there was a persistent air leak from an injury to the Table 2. Compensatory Sweating Levels Level 1 2 3 4
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Symptoms None Rare and mild Daily and moderate Severe
visceral pleura, a 10F pleural catheter brought out through the most lateral port incision and was left in place for 12 to 14 hours. The procedure was then repeated on the contralateral side. Patients who did not require a pleural drain were discharged home the afternoon of surgery. Patients who required a pleural drain or failed to meet discharge criteria were admitted overnight and discharged the next morning. Patients undergoing reoperative sympathectomy were similarly positioned and had the same initial port placements as described. Contralateral single lung ventilation and CO2 insufflation were also used. If there were extensive pleural adhesions, a third 5-mm port was placed to facilitate retraction of the lung. These patients also underwent the excision of the third thoracic sympathetic ganglion. The evacuation of pleural air, pleural drainage, and discharge intentions were the same as described for patients undergoing initial sympathectomy.
Results Over a 72-month period, 40 patients underwent bilateral (32) or unilateral (8) reoperative thoracoscopic sympathectomy for refractory (35) or recurrent (5) primary palmar hyperhidrosis. Previous methods of sympathectomy are displayed in Table 3. Of the patients undergoing a reoperative procedures, 2 had their original operative sympathectomy performed by one of the authors. All of the percutaneous ablations were thermal ablations that were intended to ablate the third thoracic sympathetic ganglion. None of these was performed by the authors. During the same period, 333 patients underwent a bilateral thoracoscopic sympathectomy for primary palmar hyperhidrosis. Of these, 321 met the inclusion criteria of this study and were analyzed. A comparison of patient demographics is seen in Table 4. Mean time from initial to reoperative sympathectomy in the reoperative patient group was 27 months and did not differ significantly between patients undergoing an initial operative or ablative sympathectomy. Operative time compared as unilateral sympathectomy was not significantly different between the two groups despite reoperative sympathectomy patients requiring the addition of a third unilateral port and or a postoperative pleural drain significantly more frequently than initial sympathectomy patients. However, the difference in the operative times between patients undergoing reoperative sympathectomy after a percutaneous ablative technique versus an operative approach nearly attained statistical significance in subset analysis (p ⫽ 0.051) reflecting the pleural adhesions encountered in each type of patient.
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Table 4. Comparison of Two Treatment Groups’ Characteristics and Outcomes
Number Unilateral Bilateral Age (mean years) Operative timea (mean min) Third trochar Pleural drain Hospital stay (mean days) Follow-up complete Symptom improvementb Compensatory sweatingc a
Measured as unilateral procedure time.
b
Initial Sympathectomy
Reoperative Sympathectomy
321 8 321 21 14 11 11 ⬍1 100% 316 (98%) 101 (31%)
40 32 27 26 22 23 1.6 100% 38 (95%) 21 (53%)
Defined as a reduction in severity to class 1 or 2 symptoms.
An attempt was made to assign a reason for failure of the original sympathectomy in each case at the time of reoperation. Despite the initial technique of sympathectomy, failure was attributable to inaccurate localization (31) or incomplete resection (7) of the sympathetic ganglion in 38 of the reoperative patients. The etiology did not vary significantly between the operative or ablative group. Thirty of 31 inaccurate localizations (97%) occurred in percutaneous ablation or thoracotomy patients, whereas this cause was identified in only 1 failure of a thoracoscopic sympathectomy. No cause for failure could be reliably assigned in 2 patients who had undergone a prior endoscopic sympathetic clip application except for the possibility of incomplete clip application by the original surgeon. A significant difference was also seen between the two patient groups related to length of stay. This was attributable exclusively to the placement of a pleural drain in reoperative patients. No patient in either group required longer than an overnight hospital stay after sympathectomy. There was not a mortality in either group of patients. There were no significant differences in the incidence of morbidity between the two groups (Table 5). No patient in either group required reoperation for bleeding or experienced a Horner’s syndrome. All 40 patients undergoing reoperative sympathectomy and 321 patients undergoing initial sympathectomy returned for their postoperative outpatient assessment. There were equal rates of symptom improvement between the two groups, defined as a reduction to class 1 or 2 symptoms on the Hyperhidrosis Disease Severity Scale. There was, however, a significant difference in patients who realized significant compensatory sweating after
c
p Value
0.053 0.0003 0.0004 0.0001 0.18 0.01 Defined as level 3 or 4 symptoms.
reoperative sympathectomy when compared with initial sympathectomy patients. No patients in either series required operative reversal of their sympathectomy for compensatory sweating. Two patients who underwent reoperative sympathectomy and 5 patients undergoing initial sympathectomy did require medical treatment of their compensatory sweating (p ⫽ 0.17).
Comment Sympathectomy as a treatment for severe hyperhidrosis is not a new concept. Although Alexander is credited with performing the first cervicothoracic sympathectomy in 1889, the first reported sympathectomy for hyperhidrosis is attributed to Kotzareff and reported in 1920 [5, 6]. Subsequently, dorsal, supraclavicular, and multiple thoracotomy approaches were developed in an attempt to minimize the patient’s experience for a benign disease [7–9]. Endoscopic sympathectomy was not reported until 1951 by Kux [10]. He went on to develop a standardized technique for the procedure accomplished using intrathoracic insufflation without endotracheal intubation. However, despite the excellent results achieved by Kux [11] in a subsequent report of 55 patients with palmar and axillary hyperhidrosis, widespread interest and adoption of endoscopic sympathectomy awaited the advances in fiberoptic technologies and instrumentation that ushered in the modern era of endoscopic surgery. Throughout the 1990s, the technique of endoscopic sympathectomy was enhanced until it had replaced all of the other techniques for thoracic sympathectomy for hyperhidrosis except one: percutaneous ablation. First reported in 1984 as a treatment for hyperhidrosis, this
Table 5. Morbidities
Pneumothorax Wound infection Pleural effusion Incision hyperesthesias
Initial Sympathectomy
Reoperative Sympathectomy
p Value
4 (1%) 6 (2%) 7 (2%) 3 (0.9%)
1 (3%) 2 (5%) 2 (5%) 1 (3%)
0.44 0.21 0.26 0.37
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Fig 1. Thoracoscopic view of pleural adhesions after a percutaneous thermal ablation.
technique utilized radiofrequency ablation, thermal coagulation, or chemical ablation to destroy a segment of the sympathetic chain with or without image guidance [12]. Proponents of the procedure, often neurosurgeons, saw the ability to offer it to their patients without the need for general anesthesia or a thoracic surgical procedure. However, the lack of direct visualization of the sympathetic chain led to rates of recurrence of symptoms and Horner’s syndrome that should be considered unacceptable when compared with the endoscopic technique in experienced hands [13]. As endoscopic sympathectomy and, to a lesser extent, percutaneous ablation have been used in increasing frequency over the last 20 years to treat primary palmar hyperhidrosis, some patients have not experienced an improvement in their symptoms. These patients can be segregated into those whose symptoms improved or completely resolve only to recur and those whose symptoms persisted after surgery. Rates of failure for endoscopic sympathectomy since 1999 have ranged between 1% and 4%, and persistence or recurrence of symptoms for percutaneous ablative techniques has been reported as high as 16% [13, 14]. While there is a paucity of literature describing the treatment of patients whose symptoms persist or recur after percutaneous ablative sympathectomy, four reports of reoperative endoscopic sympathectomy do exist. Orteu and colleagues [15] and Sing and coworkers [16] separately published case reports of patients who required reoperative sympathectomy for hyperhidrosis in 1995 and 1998, respectively. Hsu and coworkers [17] were the first to publish a series of patients requiring reoperative sympathectomy for palmar or axillary hyperhidrosis in 1998. All 20 of these patients had undergone previous endoscopic sympathectomy, with 19, or 95%, realizing relief of their symptoms after reoperation. The overwhelming reason for failure of the initial sympathectomy in these patients according to the authors was an inadequate or inaccurate initial sympathectomy.
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Lin and colleagues [18] subsequently published what remains the largest series of patients undergoing reoperative sympathectomy for persistent or recurrent palmar hyperhidrosis. All of these patients had undergone an initial endoscopic sympathectomy. The authors reported that all patients in this series experienced resolution of their hyperhidrosis after reoperative sympathectomy but experienced an 86% incidence of compensatory sweating. This investigation also demonstrates the effectiveness of reoperative sympathectomy for patients experiencing persistent or recurrent primary palmar hyperhidrosis after a previous sympathectomy. However, unlike the previously discussed reports, the methods of initial sympathectomy in this series were diverse and included axillary and posterior thoracotomies as well as a large number of patients who underwent percutaneous ablation. The results of reoperative sympathectomy in these patients have not been previously reported. These different techniques produced varying degrees of pleural adhesions, which were not predictable based on the original form of sympathectomy and which accounted for the significant differences in pleural drainage and length of stay between the two patient groups. In fact, the authors observed some of the most dense and widespread adhesions in patients who had undergone a percutaneous ablation as their initial procedure (Fig 1). However, the technique of initial sympathectomy did result in technique specific reasons for failure. Inaccurate localization accounted for all of the failures of patients undergoing percutaneous ablation and alternative forms of thoracotomy, and incomplete resection of the sympathetic ganglion remained the common finding in patients who had previously undergone an endoscopic sympathectomy (Fig 2). These findings are intuitive, understanding that the percutaneous technique uses external landmarks to localize the area of the sympathetic chain, and that the two forms of thoracotomy used generally provide poor exposure to this area, especially on the right. Endoscopic sympathectomy provides excellent vi-
Fig 2. Incomplete clip occlusion of the sympathetic ganglia.
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sualization of the sympathetic chain, with failures in these patients resulting almost exclusively failing to provide a complete form of sympathectomy. Despite these differences, this investigation found that the effectiveness of reoperative endoscopic sympathectomy remained high while morbidity and length of stay were acceptable. Compensatory sweating, however, was significantly more common in the reoperative group despite attempting to perform the same resection as patients undergoing initial sympathectomy received. While it is unclear why this should be observed, it is most likely because of the effects of a second procedure, which may have produced an effect similar to a more extensive sympathectomy. Although this investigation reports the largest group of patients in the literature undergoing reoperative endoscopic sympathectomy after various initial procedures, some weaknesses do exist in its design. As in any unusual condition, the absolute number of patients in this study remains small. Also, although all patients included were considered to have failed medical therapy, patients were not randomly assigned to a nonsurgical treatment. The author’s standard follow-up scheme was also utilized for all of the patients in this review. Rates of compensatory sweating in both patient groups and rates of recurrence in patients undergoing an initial sympathectomy might benefit from a longer period of postoperative observation. In conclusion, this investigation found that, despite widely disparate techniques of initial sympathectomy for primary palmar hyperhidrosis, reoperative endoscopic sympathectomy is highly effective for patients who have persistent or recurrent symptoms. Reoperative sympathectomy is likely to encounter varying degrees of pleural adhesions, resulting in the increased need for postoperative pleural drainage and hospital admission. The incidence of significant compensatory sweating is also increased among patients undergoing reoperative sympathectomy. With these factors involved in the informed consent process, reoperative endoscopic sympathectomy should be offered by surgeons experienced in the technique to patients with severe persistent or recurrent symptoms of primary palmar hyperhidrosis after an unsuccessful sympathectomy, regardless of the initial technique used.
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References 1. Miller DL, Force SD. Outpatient microthoracoscopic sympathectomy for palmar hyperhidrosis. Ann Thorac Surg 2007; 83:1850 –3. 2. Kwong KF, Cooper LB, Bennett LA, Burrows W, Gamliel Z, Krasna MJ. Clinical experience in 397 consecutive thoracoscopic sympathectomies. Ann Thorac Surg 2005;80:1063– 6. 3. Doolabh N, Horswell S, Williams M, et al. Thoracoscopic sympathectomy for hyperhidrosis: indications and results. Ann Thorac Surg 2004;77:410 – 4. 4. Strutton DR, Kowalski JW, Glaser DA, et al. US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol 2004;51:241– 8. 5. Drott C. The history of cervicothoracic sympathectomy. Eur J Surg 1994;572(Suppl):5. 6. Kotzareff A. [Resection partielle du tronc droit du grand sympathique cervical pour hyperdrose unilateral de meme cote.] Rev Med Suisse Romande 1920;40:111–3. 7. Adson AW. Changes in technique of cervicothoracic ganglionectomy and trunk resection. Am J Surg 1931;23:287– 8. 8. Teleford ED. The technique of sympathectomy. Br J Surg 1935;23:448 –50. 9. Atkins HJB. Sympathectomy by the axillary approach. Lancet 1954;1:538 –9. 10. Kux E. The endoscopic approach to the vegetative nervous system and its therapeutic possibilities. Dis Chest 1951;20: 13– 47. 11. Kux M. Thoracic endoscopic sympathectomy in palmar and axillary hyperhidrosis. Arch Surg 1978;113:264 – 6. 12. Wilkinson HA. Percutaneous radiofrequency upper thoracic sympathectomy: a new technique. Neurosurgery 1984;15: 11– 4. 13. Chuang KS, Liu JC. Long-term assessment of percutaneous stereotactic thermocoagulation of upper thoracic ganglionectomy and sympathectomy for palmar and craniofacial hyperhidrosis in 1742 cases. Neurosurgery 2002;51:963–9. 14. Dumont P. Side effects and complications of surgery for hyperhidrosis. Thorac Surg Clin 2008;18:193–207. 15. Orteu CH, McGregor JM, Almeyda JR, Rustin MHA. Recurrence of hyperhidrosis after endoscopic transthoracic sympathectomy: case report and review of the literature. Clin Exp Dermatol 1995;20:230 –3. 16. Singh B, Moodley J, Haffejee AA, Ramdial PK, Robbs JV, Rajaruthnam P. Resympathectomy for sympathetic regeneration. Surg Laparosc Endosc 1998;8:257– 60. 17. Hsu CP, Chen CY, Hsia JY, Shai SE. Resympathectomy for palmar and axillary hyperhidrosis. Br J Surg 1998;85:1504 –5. 18. Lin TS. Video-assisted thoracoscopic resympathectomy for palmar hyperhidrosis. Analysis of 42 cases. Ann Thorac Surg 2001;72:895– 8.
DISCUSSION DR MARK J. KRASNA (Towson, MD): Doctor Reed, Dr Meyers, members and guests. I want to thank Dr Freeman and his colleagues for providing me with the manuscript and congratulate him on an excellent presentation. Thoracoscopic sympathectomy is a safe, simple and straightforward operation performed for many different indications, primarily done in this country for hyperhidrosis, a socially debilitating condition that affects almost 1% of the population worldwide. Despite the fact that there is a straightforward operation described to treat this condition, there is much controversy about the indications and the preferred surgical technique for performing sympathectomy. This is evidenced by the high proportion of malpractice cases in the United States that relate to this procedure currently.
This presentation describes a subgroup of patients rarely discussed in the thoracic literature, that is, patients who have suffered from a failed sympathectomy after either a previous thoracic surgical procedure or a previous percutaneous nerve ablation intervention. During this 6-year period, 40 patients of a total of almost 360 patients at their facility had surgery for repeat sympathectomy; 25 of these were for percutaneous ablation and 15 for prior sympathectomy. The authors have found that the redo sympathectomy was feasible with only minor additional morbidity, minor additional operating room time, and slightly longer duration of chest tube drainage. The success rates were the same among both groups, although the incidence of compensatory sweating was significantly worse in the redo group. I have three questions for Dr Freeman.
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First, you note that the patients were assessed before and 2 months after sympathectomy. Our practice has been to follow up with patients either in person or by letter at least 2 more times during the postoperative period to assure that the patients complete their questionnaires at least one time during the summer season. Have you done this, or do you know the seasonal variation of your postoperative visits? Obviously, patients who are being followed up in Indiana in the wintertime may give better than average results. Second, do you think that there is a difference between the two treatment groups, namely, those who had prior surgical sympathectomy versus those who had a percutaneous ablation? I know the numbers would be small, but have you had a chance to look at the subgroups and compare the differences in success rate among them? Finally, one question regarding your technique. You describe the anesthesia technique as using a bronchial blocker. Does this mean that the patient was first bronchoscoped to place the blocker on one side and then rescoped to place the blocker on the other side, or did you just use the CO2 and only drop one lung? And then, again, on the surgical technique side, you describe excising the sympathetic ganglia. That is something that has rarely been described recently in the thoracic literature. Has your group tried in the past either cutting, ablating, or clipping the nerve above and below the ganglion rather than actually excising it? Again, I want to thank the Association for the privilege of discussing the paper, and I congratulate you and your authors for a well-written manuscript and a well-presented series. DR FREEMAN: Thank you, Dr Krasna. It is a pleasure to have you review our paper in light of your contributions to this subject, and I will answer your questions in order. To be honest with you, we have not really considered when we do our follow-ups. In my practice, when I look at my office, these are the highest rate of no-show patients, both for new consultation and for follow-up, to the point that I have had to limit the number of these patients that I will see in one day because of the cancellations. We have a bimodal distribution, winter break, summer, because of the age of the patients. So most of the patients are operated on in the summer, and most of them still get their follow-up in the time when it is still warm, but that is a very good point. Looking at the subpopulations, there is a very large difference in our small experience between patients who have had surgery and patients who had an ablation. The patients who had an ablation, they didn’t get close to the sympathetic ganglion was the bottom line. So when we go in there, there are a lot of adhesions, you take that down, and then it is a straightforward surgery. The patients who had had prior surgical sympathectomy were a mixed bag; some had clips, some had the wrong ganglion worked on, et cetera, et cetera. So really, in the ablation patients, they just missed the sympathetic ganglia. As far as the blocker, we use the bronchial blocker for almost all our procedures that we need, contralateral, single lung, ventilation, all except lung transplant, and have been very happy with it. The anesthesiologist places it on one side. We gently insufflate some CO2. As soon as we are done, they are repositioning the blocker while we are evacuating air before we move to the next side.
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DR ROBERT J. CERFOLIO (Birmingham, AL): Congratulations. I think we have a unique opportunity here with all the experts in the room to answer some questions that I don’t think we know the answer to. Now, you showed that 10 people had clips and failed. Is anybody in the room using clips routinely? Nobody. Clips only. Has anybody taken a clip off to treat compensatory hyperhidrosis, which is the reason people went to clips in the first place? Have you? DR FREEMAN: No, I don’t clip. DR CERFOLIO: Does it work or is the nerve dead? So the advantage of the clip was to treat compensatory hyperhidrosis. I am unsure of the data that it does reverse compensatory hyperhidrosis, but I have heard personal reports from some that it does. Until we have data that it does, and since the failure rate may be higher with clipping instead of cutting the nerve, should we be clipping? DR FREEMAN: Almost everybody in my office has been on the Internet and they say, do you clip? DR CERFOLIO: Right, I get the same question, but can we get something out there now with data and all the world’s experts here, or at least southern experts, that we should or shouldn’t be clipping? DR FREEMAN: In my opinion, yes, because if the hyperhidrosis goes away, it means the nerve is dead. DR CERFOLIO: Right, I am agreeing with you, but I want to hear that from a group of experts. DR KRASNA: Just a comment. There are no prospective randomized data in the literature that will show that clipping is better in any way than sympathectomy or sympathecotomy. I think what you have pointed out, though, is, for whatever reason, in your practice the majority of failures were among clips. But I don’t know that we can say quite what you said yet, Cerf. DR DANIEL L. MILLER (Atlanta, GA): Could you tell us briefly about the percutaneous ablation technique and the patients who failed treatment? DR FREEMAN: The percutaneous patients who failed? DR MILLER: No, the patients who had undergone a redo procedure. Why did they fail? Was it a wrong level? Did they miss the nerve? Was an accessory nerve still intact? More details would be greatly appreciated. Thank you. DR FREEMAN: In general, there are three percutaneous techniques: thermal, radiofrequency, or chemical. There has been a large series reported from China, and in this country, neurosurgeons are very much a proponent of this because they can offer that and they can’t offer the other thing. So I came after a neurosurgeon who did a bunch of these, and that is why we have those in our practice. They failed because they just didn’t get to the right spot in our series. I don’t have the denominator, so I can’t tell you how many of them worked. But that is why they failed in our series.
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