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[Image-guided pain therapy. Sympathicolysis].

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[Image-guided pain therapy. Sympathicolysis].

Radiologe. 2015 Jun;55(6):462-9

Authors: Burbelko M, Wagner HJ, Gutberlet M, Grothoff M

Abstract
BACKGROUND: In the autonomic nerve system most sympathetic neurons synapse peripherally in the ganglia of the sympathetic trunk. A reduction in sympathicotonia by partial elimination of these ganglia is a therapeutic approach that has been used for more than 100 years. In the early 1920s the first attempts at percutaneous sympathicolysis (SL) were carried out. Nowadays, minimally invasive image-guided SL has become an integral part of interventional radiology. Established indications for SL are hyperhidrosis, critical limb ischemia and the complex regional pain syndrome.
METHODS: The standard imaging guidance modality in SL is computed tomography (CT) which allows the exact placement of the puncture needle in the target area under visualization of the surrounding structures. Ethanol is normally used for chemical lysis, which predominantly eliminates the unmyelinated autonomic axons. In order to visualize the distribution of the ethanol during application, iodine-containing contrast medium is added.
RESULTS: The sympathetic nervous system (SNS) controls sweat secretion via the efferent neurons; therefore, effective therapy of idiopathic palmar, axillary and plantar hyperhidrosis can be achieved when SL is performed at the corresponding level of the sympathetic trunk. Furthermore, due to the vasomotor innervation of most blood vessels, by reduction of the sympathicotonus an atony of the smooth muscles and therefore vasodilatation occurs, which is used as a palliative therapeutic option in patients with critical limb ischemia. By elimination of the afferent sensory fibers this also results in pain relief. This principle is also used in the SL therapy of the complex regional pain syndrome.
CONCLUSION: After the introduction of CT guidance, major complications have become rare events. In addition to the usual risks of percutaneous interventions there are, however, a number of specific complications, such as syncope caused by irritation of cardiac sympathetic nerves in thoracic SL and ureteral injury in lumbar SL.

PMID: 26063075 [PubMed – indexed for MEDLINE]

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Unilateral sequential endoscopic thoracic sympathectomy for palmar hyperhidrosis: a proposed technique to overcome compensatory hyperhidrosis and improve plantar hyperhidrosis.

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Unilateral sequential endoscopic thoracic sympathectomy for palmar hyperhidrosis: a proposed technique to overcome compensatory hyperhidrosis and improve plantar hyperhidrosis.

J Laparoendosc Adv Surg Tech A. 2015 May;25(5):370-4

Authors: Youssef T, Soliman M

Abstract
BACKGROUND: Although endoscopic thoracic sympathectomy (ETS) offers permanent cure of palmar hyperhidrosis (PH), compensatory hyperhidrosis (CH) often complicates the procedure. We analyzed the outcomes of a 2-month interval for unilateral sequential ETS (S-ETS) in comparison with simultaneous bilateral ETS (B-ETS), notably regarding CH and associated plantar hyperhidrosis, in treating patients with PH.
PATIENTS AND METHODS: Four hundred seven patients with intractable PH were randomly assigned into two groups: the B-ETS group (204 patients) and the S-ETS group (203 patients).
RESULTS: Three hundred sixty-four patients completed the study. Complication rates were comparable for both groups. No patient died perioperatively, and no conversion was necessary. Treatment success on follow-up was 97.2% for S-ETS and 96.7% for B-ETS. The incidence of CH was decreased substantially from 131 (71.1%) patients in the B-ETS group to 22 (12.2%) patients in the S-ETS group (P<.001), with no patient suffering severe CH in the S-ETS group compared with 33 (25.5%) patients in the B-ETS group. Eighty-four (58.3%) patients in the S-ETS group had simultaneous disappearance or decreased perspiration on the soles. All patients in the S-ETS group were satisfied, whereas 37.9% of B-ETS patients were unsatisfied with their operation, mostly because of CH and recurrences.
CONCLUSIONS: Although both sympathectomies were effective, safe, and minimally invasive methods for treatment of PH, unilateral sequential ETS appeared to be a more optimal technique in terms of reduction of CH to a minimum and improvement of associated plantar hyperhidrosis.

PMID: 25768057 [PubMed – indexed for MEDLINE]

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Long-term results of the use of oxybutynin for the treatment of plantar hyperhidrosis.

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Long-term results of the use of oxybutynin for the treatment of plantar hyperhidrosis.

Int J Dermatol. 2015;54(5):605-11

Authors: Wolosker N, Teivelis MP, Krutman M, de Paula RP, Kauffman P, de Campos JR, Puech-Leão P

Abstract
BACKGROUND: Plantar hyperhidrosis is a common illness with significant impact on quality of life. Oxybutynin presents good short-term results, but longer follow-up results are lacking. We evaluated oxybutynin effectiveness in patients who were not surgically treated and who had at least six months of follow-up.
METHODS: From September 2007 to September 2013, 85 consecutive patients were enrolled in our institutional protocol for the “pharmacological-first” treatment of primary plantar hyperhidrosis with oxybutynin. Eight patients were lost to follow-up, 15 patients have not yet been under treatment for six months, and data were available for 39 patients (all female) treated for at least six months. Data at the start of the protocol, six weeks after beginning treatment, and at their final visit were analyzed.
RESULTS: Twenty-three of the 77 patients (29.87%) did not improve after pharmacological therapy. From the 39 patients with more than six months of follow-up (median 16.9 months, range 9-71), 79.5% reported moderate/great improvement in excessive plantar sweating after six weeks of treatment, and this rate increased to 84.7% in the last follow-up visit; 82.85% showed improvement in other sites presenting hyperhidrosis. Dry mouth was the most common side effect; 51.6% of patients reported it to be moderate/severe at the last visit.
CONCLUSION: In patients with good initial response to oxybutynin, more than 82% presented moderate or great improvement in plantar and other sites’ excessive sweating; dry mouth was the most common side effect but was tolerable and did not lead any patient to interrupt treatment.

PMID: 25600990 [PubMed – indexed for MEDLINE]

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Long-Term Efficacy of Oxybutynin for Palmar and Plantar Hyperhidrosis in Children Younger than 14 Years.

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Long-Term Efficacy of Oxybutynin for Palmar and Plantar Hyperhidrosis in Children Younger than 14 Years.

Pediatr Dermatol. 2015 Sep-Oct;32(5):663-7

Authors: Wolosker N, Teivelis MP, Krutman M, de Paula RP, Schvartsman C, Kauffman P, de Campos JR, Puech-Leão P

Abstract
Oxybutynin for treating hyperhidrosis in children has been evaluated only in short-term studies. We aimed to investigate the long-term effects of oxybutynin in treating children with palmar and plantar hyperhidrosis who had not undergone surgery and who were monitored for at least 6 months (median 19.6 mos). A cohort of 97 patients was evaluated retrospectively, with particular attention to 59 children (ages 4-14 yrs) who were treated for longer than 6 months. Their quality of life (QOL) was evaluated using a validated clinical questionnaire before and after 6 weeks of pharmacologic therapy. A self-assessment of hyperhidrosis was performed after 6 weeks and after the last consultation. By their final office visit, more than 91% of the children with hyperhidrosis treated with oxybutynin experienced moderate or great improvement in their level of sweating and 94.9% experienced improvement in QOL. More than 90% of children reported improvement of hyperhidrosis at other sites. Dry mouth was the most common side effect. Oxybutynin appears to be an effective treatment option for children with hyperhidrosis, and positive results are maintained over the long term (median 19.6 mos).

PMID: 25490865 [PubMed – indexed for MEDLINE]

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Quality of life after endoscopic lumbar sympathectomy for primary plantar hyperhidrosis.

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Quality of life after endoscopic lumbar sympathectomy for primary plantar hyperhidrosis.

World J Surg. 2015 Apr;39(4):905-11

Authors: Rieger R, Pedevilla S, Lausecker J

Abstract
BACKGROUND: Primary plantar hyperhidrosis is characterised by excessive secretion of the sweat glands of the feet and may lead to significant limitations in private and professional lifestyle. The aim of this prospective study was to assess the effect of endoscopic lumbar sympathectomy (ESL) on the quality of life (QL) of patients with primary plantar hyperhidrosis.
METHODS: Bilateral ESL was performed on 52 patients, 31 men and 21 women with primary plantar hyperhidrosis. Perioperative morbidity and clinical results were evaluated in all patients after a mean follow-up of 15 months. Postoperative QL was examined with the SF-36V2 questionnaire and the hyperhidrosis-specific questionnaires devised by Milanez de Campos and Keller.
RESULTS: All procedures were carried out endoscopically with no perioperative morbidity. Plantar hyperhidrosis was eliminated in 50 patients (96%) and two patients (4%) suffered a relapse. Unwanted side effects occurred in the form of compensatory sweating in 34 (65%) and in the form of postsympathectomy neuralgia in 19 patients (37%). Ninety six percentage of patients were satisfied with the postoperative result and 88% would have the surgery repeated. The SF-36V2 questionnaire revealed a significant improvement of QL after lumbar sympathectomy in physical health (physical component summary, p < 0.01) as well as mental health (mental component summary, p < 0.05). Improved QL was also demonstrated in the Milanez de Campos questionnaire in the dimensions functionality/social interactions (p < 0.01), intimacy (p < 0.01), emotionality (p < 0.01) and specific circumstances (p < 0.01) as well as in the Keller questionnaire in the area of plantar hyperhidrosis (p < 0.01).
CONCLUSION: The performance of an ESL in patients with primary plantar hyperhidrosis leads to the effective elimination of excessive sweat secretion of the feet and to an increase in QL.

PMID: 25476759 [PubMed – indexed for MEDLINE]

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Quality of life after sympathetic surgery at the T4 ganglion for primary hyperhidrosis: clip application versus diathermic cut.

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Quality of life after sympathetic surgery at the T4 ganglion for primary hyperhidrosis: clip application versus diathermic cut.

Int J Surg. 2014 Dec;12(12):1478-83

Authors: Panhofer P, Ringhofer C, Gleiss A, Jakesz R, Prager M, Bischof G, Neumayer C

Abstract
INTRODUCTION: Limited procedures at the T4 ganglion show low rates of compensatory sweating (CS). The aim of the study was to compare endoscopic sympathetic block (ESB) via clip application with endothoracic sympathicotomy (ETS) via diathermy with special regard on patients’ quality of life (Qol).
PATIENTS AND METHODS: Treatment success, side effects and patient satisfaction were evaluated in a prospectively gathered database of a tertiary-care referral hospital. Two disease-specific Qol questionnaires were used (Keller, Milanez de Campos).
RESULTS: 406 operations were performed in 205 patients (ESB4 N = 114, ETS4 N = 91) with a median follow-up of 12 months. Both procedures improved Qol significantly (P < 0.001) and the degree of improvement was equal in both groups. Palmar and axillary HH were ameliorated after both procedures (P < 0.001). Accordingly, plantar HH decreased after ESB4 (P = 0.002), while remaining unaltered after ETS4. Nineteen patients (9.3%) reported CS and 10 patients (4.9%) judged it as "disturbing". Nine of the latter belonged to the ETS4 group compared to one ESB patient (P = 0.015). Patients developed higher rates of plantar CS after ETS4 compared to ESB4 (P = 0.006). Five patients (2.4%) from both cohorts reported persistence of axillary HH. Recurrence of axillary symptoms was found in 5 ESB4 patients. Satisfaction rates did not differ significantly.
CONCLUSION: Patients’ Qol and satisfaction rates are similar in both treatment groups for upper limb HH. Outcome and recurrence rates speak in the favor of ETS4, severity of CS and potential reversibility argue for ESB4.

PMID: 25463770 [PubMed – indexed for MEDLINE]

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3-year follow-up after uniportal thoracoscopic sympathicotomy for hyperhidrosis: undesirable side effects.

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3-year follow-up after uniportal thoracoscopic sympathicotomy for hyperhidrosis: undesirable side effects.

J Laparoendosc Adv Surg Tech A. 2014 Nov;24(11):782-5

Authors: Karamustafaoglu YA, Kuzucuoglu M, Yanik F, Sagiroglu G, Yoruk Y

Abstract
OBJECTIVE: Endoscopic thoracic sympathectomy or sympathicotomy, for the treatment of palmar, axillary, and plantar hyperhidrosis, is generally performed at one or two levels, between T2 and T5. Compensatory sweating (CS) is a severe and undesirable side effect of this procedure. Here, we describe the success of treatment and degree of postoperative CS in sympathicotomy patients.
SUBJECTS AND METHODS: This study included 80 patients treated by uniportal (5-mm) thoracoscopic sympathicotomy (electrocautery) for primary hyperhidrosis over a 6-year period (2007-2013). Sympathicotomy was performed bilaterally at T2 for blushing (n=2), T2-T3 for palmar-only hyperhidrosis (n=34), T2-T4 for palmar and axillary hyperhidrosis (n=39), and T3-T4 for axillary-only hyperhidrosis (n=5). Outcome was assessed 2 weeks postsurgery at the clinic and annually thereafter by telephone questionnaire. Mean follow-up time was 35.2±23.3 months. Questionnaires assessed patients’ degree of sweating, postoperative CS, overall satisfaction, and complications.
RESULTS: Seventy-one patients (88.7%) were very satisfied, whereas only 9 (11.3%) were dissatisfied with the procedure. Complication incidence was 7.5%, and CS occurred in 77.5% of patients. Therapeutic success rate was 97.5%; complete relief of hyperhidrosis was achieved in 72 (90%) patients, whereas 8 (10%) experienced recurrence.
CONCLUSIONS: CS is a frequent side effect of thoracoscopic sympathicotomy. We recommend all patients undergoing this procedure should be warned of the potential risk of developing severe CS.

PMID: 25376004 [PubMed – indexed for MEDLINE]

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Botulinum neurotoxin treatment of palmar and plantar hyperhidrosis.

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Botulinum neurotoxin treatment of palmar and plantar hyperhidrosis.

Dermatol Clin. 2014 Oct;32(4):505-15

Authors: Weinberg T, Solish N, Murray C

Abstract
Palmar and plantar hyperhidrosis is relatively common and can have severe psychological and medical consequences for those afflicted. A multitude of treatments exist but are often inadequate especially for those with significant disease. In these cases botulinum neurotoxin provides a reliable method for reducing the symptoms and improving quality of life. Although actual administration is relatively straightforward, pain management is a crucial component that requires a mastery of several techniques. Patients have a high degree of satisfaction with botulinum neurotoxin treatment and are motivated to come back for repeat treatments, usually every 6 months.

PMID: 25152344 [PubMed – indexed for MEDLINE]

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Iontophoresis for palmar and plantar hyperhidrosis.

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Iontophoresis for palmar and plantar hyperhidrosis.

Dermatol Clin. 2014 Oct;32(4):491-4

Authors: Pariser DM, Ballard A

Abstract
Iontophoresis is a safe, efficacious, and cost-effective primary treatment of palmar and plantar hyperhidrosis. Decades of clinical experience and research show significant reduction in palmoplantar excessive sweating with minimal side effects. To get the best results from iontophoresis, health care professionals need to provide education on the mechanism of action and benefits, evidence of its use, and creation of a future patient-specific plan of care for continued treatments at home or in the physician’s office. Iontophoresis may be combined with other hyperhidrosis treatments, such as topical antiperspirants and botulinum toxin injections.

PMID: 25152342 [PubMed – indexed for MEDLINE]