CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 4, May 2013
AFRICA
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noted that the majority of surgeons tend to use electrocoagulation,
perhaps because of its simplicity and shorter surgical time.
Thoracoscopic resection of the upper thoracic sympathetic
chain has been defended by numerous authors over the last
decade as the treatment of choice for hyperhydrosis.
12,13
As
previously reported by Garcia and Espania in all cases via
video-assisted thorascopic surgery: one or more ganglia between
T2 and T5 are usually resected depending on the area affected
by hyperhydrosis.
14
They recommend intervention on the T2
ganglia for craniofacial hyperhydrosis or rubor, on the T3 ganglia
for palmar hyperhidrosis, and on the T3 and T4 ganglia for
combined palmar and axillary hyperhydrosis.
Using the Lin-Teleranta classification as a basis, the results
of various authors can be analysed, finding enough differences
between them to not be able to categorically indicate the precise
levels for action, but at the same time finding enough evidence
to recommend specific cut levels:
•
Patients with facial flushing and/or sweating, cut level T2
and/or T3.
•
Patients with palmar hyperhydrosis, cut level T3 and/or T4.
•
Patients with axillary hyperhydrosis, cut level T4 or T4–T5.
15-17
In our study, T2 resection was performed in 44 patients with
craniofacial hyperhydrosis, T3 resection was performed in 94
patients with only palmar and only axillary hyperhydrosis,
T3–T4 resection was performed in 175 patients with palmar and
axillary hyperhydrosis, and T3–T5 resection was performed in
22 patients with palmar and pedal hyperhydrosis.
Studies of patient series in which primary hyperhydrosis
has been treated surgically reveal a high degree of patient
satisfaction. The best results are reported by Lardinois and Ris,
with improvement in quality of life in 94.6% of the patients,
and Cohen
et al
., with a satisfaction rate of 98.2%.
18,19
The
most frequent postoperative complication is the appearance
of pneumothorax, which is usually small and requires pleural
drainage in 30% of cases. In a few patients, pleural effusion,
haemothorax or chylothorax can occur.
20
In general, pain is moderate and is resolved with conventional
analgesics over a maximum period of two to four weeks. Horner
syndrome appears permanently in less than 0.5% of cases.
Other less frequent complications are subcutaneous emphysema,
infection of the surgical wound, the presence of segmental
atelectasis and transitory lesions of the brachial plexus.
21
In our study, most of the patients presented with an
improvement in primary hyperhydrosis. The initial cure rate
was 95% and the initial satisfaction rate was 93%. There was
no mortality and no recurrence was reported at the follow-up
period. The complication rate was 15.82% in 53 patients. CS was
the most frequent complication in 34 (10.14%) cases.
CS remains the most common and most disabling
complication of video-assisted thoracoscopic sympathectomy
and it is believed to be due to a thermoregulatory mechanism.
2
CS is defined as intense sweating in other anatomical areas after
sympathectomy. The most frequent sites are the thorax, back,
abdomen and inguinal region.
22
This situation can change over
time and is usually difficult to evaluate. The reported frequencies
vary considerably, with conflicting views as to its severity and
predisposition. Factors such as geographic location, working
environment, climatic conditions (temperature and humidity),
together with heterogeneity of the population can also affect the
incidence of CS.
According to the series reviewed by Dumont, the mild
form oscillates between 15 and 90% and the severe form
between 1 and 30%.
21
According to some authors, the higher
up the sympathectomy is done (T2) and the more extensive the
resection (T2–T5), the greater the probability of there being
serious CS.
20,21
We had 34 cases with compensatory sweating.
In our experience, if you protect the T2 ganglion, you have less
reflex compensatory sweating.
Conclusion
Bilateral video-assisted thoracic sympathectomy is currently
a standard surgical technique to treat primary hyperhydrosis
because it is a safe, easy, fast, effective and minimally invasive
method. Despite the appearance of postoperative changes such
as CS, patient satisfaction with the procedure is high and their
quality of life improves.
References
1.
Drott C, Gothberg G, Claes G. Endoscopic transthoracic sympathec-
tomy: an efficient and safe method for the treatment of hyperhidrosis
. J
Am Acad Dermatol
1995;
33
: 78–81.
2.
Chou SH, Kao EL, Lin CC, Chang YT, Huang MF. The importance of
classification in sympathetic surgery and a proposed mechanism for
compensatory hyperhidrosis: experience with 464 cases.
Surg Endosc
2006;
20
(11): 1749–1753.
3.
Ro KM, Cantor RM, Lange KL, Ahn SS. Palmar hyperhidrosis:
evidence of genetic transmission.
J Vasc Surg
2002;
35
: 382–386.
4.
Hornberger J, Grimes K, Naumann M, Glaser DA, Lowe NJ, Naver H,
et al.
Multi-Specialty Working Group on the Recognition. Diagnosis
and Treatment of primary focal hyperhidrosis.
J Am Acad Dermatol
2004;
51
: 274–286.
5.
Stolman LP. Treatment of hyperhidrosis.
Dermatol Clin
1998;
16
:
863–867.
6.
Shelly WB, Talanin NY, Shelly ED. Botulinum toxin therapy for palmar
hyperhidrosis.
J Am Acad Dermatol
1998;
38
: 227–229.
7.
Hashmonai M, Kopelman D. History of sympathetic surgery.
Clin
Auton Res
2003;
1
: 16–19.
8.
Hughes J. Endothoracic sympathectomy.
Proc R Soc Med
1942;
35
:
585–586.
9.
Sihoe AD, Ho KM, Sze TS, Lee TW, Yim AP. Selective lobar collapse
for video-assisted thoracic surgery.
Ann Thorac Surg
2004;
77
:
278–283.
10. Hsieh YJ, Chen CM, Lin HY, Young TF. Experience of anesthesia
during transthoracic endoscopic sympathectomy for palmar hyperhidro-
sis: comparison between double-lumen endobronchial tube ventilation
and laryngeal mask ventilation.
Acta Anaesthesiol Sin
1994;
32
: 13–20.
11. Hashmonai M, Assalia A, Kopelman D. Thoracoscopic sympathectomy
for palmar hyperhidrosis. Ablate or resect?
Surg Endosc
2001;
15
:
435–441.
12. Kim BY, Oh BS, Park YK, Jang WC, Suh HJ, Im YH. Microinvasive
video-assisted thoracoscopic sympathicotomy for primary palmar
hyperhidrosis.
Am J Surg
2001;
181
: 540–542.
13. Krasna MJ, Demmy TL, McKenna RJ, Mack MJ. Thoracoscopic
sympathectomy: the U.S. experience.
Eur J Surg
1998;
580
(Suppl):
19–21.
14. Garcia F, Espania A. Usefulness of bilateral sympathectomy using
video-assisted thorascopic surgery in the treatment of essential hyper-
hidrosis.
ActasDermosifiliogr
2008;
99
: 523–711.
15. Moya J, Ramos R, Morera R, Villalonga R, Perna V, Macia I,
et al
.
Resultados de la simpaticólisis y la simpatectomía torácica superior-
bilateral endoscópica en eltratamiento de la hiperhidrosis primaria.
Estudio de 1.016 procedimientos.
Arch Bronconeumol
2006;
42
:
230–234.
16. Lin CC, Telaranta T. Lin-Telaranta classification: the importance of
different procedures for different indications in sympathetic surgery.
