Category: Sympathectomy

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Hyperhidrosis: Management Options.

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Hyperhidrosis: Management Options.

Am Fam Physician. 2018 Jun 01;97(11):729-734

Authors: McConaghy JR, Fosselman D

Abstract
Hyperhidrosis is excessive sweating that affects patients’ quality of life, resulting in social and work impairment and emotional distress. Primary hyperhidrosis is bilaterally symmetric, focal, excessive sweating of the axillae, palms, soles, or craniofacial region not caused by other underlying conditions. Secondary hyperhidrosis may be focal or generalized, and is caused by an underlying medical condition or medication use. The Hyperhidrosis Disease Severity Scale is a validated survey used to grade the tolerability of sweating and its impact on quality of life. The score can be used to guide treatment. Topical aluminum chloride solution is the initial treatment in most cases of primary focal hyperhidrosis. Topical glycopyrrolate is first-line treatment for craniofacial sweating. Botulinum toxin injection (onabotulinumtoxinA) is considered first- or second-line treatment for axillary, palmar, plantar, or craniofacial hyperhidrosis. Iontophoresis should be considered for treating hyperhidrosis of the palms and soles. Oral anticholinergics are useful adjuncts in severe cases of hyperhidrosis when other treatments fail. Local microwave therapy is a newer treatment option for axillary hyperhidrosis. Local surgery and endoscopic thoracic sympathectomy should be considered in severe cases of hyperhidrosis that have not responded to topical or medical therapies.

PMID: 30215934 [PubMed – in process]

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Efficacy of Miniuniportal Video-Assisted Thoracoscopic Selective Sympathectomy (Ramicotomy) for the Treatment of Severe Palmar and Axillar Hyperhidrosis.

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Efficacy of Miniuniportal Video-Assisted Thoracoscopic Selective Sympathectomy (Ramicotomy) for the Treatment of Severe Palmar and Axillar Hyperhidrosis.

Thorac Cardiovasc Surg. 2018 May 08;:

Authors: Akil A, Semik M, Fischer S

Abstract
BACKGROUND:  Video-assisted thoracoscopic surgery (VATS) clipping of the sympathetic branch has become the standard approach for the treatment of essential hyperhidrosis when conservative treatment failed. However, this is associated with relevant potential complications such as postoperative compensatory sweating and recurrent sweating. We report the outcome after selective sympathectomy (ramicotomy) through a miniuniportal VATS approach in patients with therapy-refractory palmar and/or axillary hyperhidrosis.
METHODS:  A total of 51 consecutive patients (37 females, mean age: 30 years, range: 12-64 years) who suffered from therapy-refractory palmar and/or axillary severe hyperhidrosis were included. Data were prospectively collected and retrospectively analyzed. All patients underwent bilateral miniuniportal VATS ramicotomy. Duration of surgery, hospital stay, recurrent, and compensatory sweating were documented.
RESULTS:  All patients had palmar sweating, where 51% had additional axillary sweating and 57% had additional plantar sweating. In all patients, selective division of the rami communicantes of the thoracic sympathetic ganglions Th2 to Th5 was performed. The mean duration of bilateral surgery for both sides was 67 ± 2.5 minutes. The mean postoperative hospital stay was 2 ± 1 days. After surgery and at further follow-up (mean: 12 ± 2.5 months), all patients presented dry and warm hands and axillae, without any evidence of compensatory or recurrent sweating. All patients described a remarkable increase in quality of life.
CONCLUSION:  Miniuniportal VATS ramicotomy represents a feasible surgical technique with a very high success and satisfaction rate. Therefore, this approach should be considered as the method of choice for the treatment of patients with severe therapy-refractory palmar and axillary hyperhidrosis.

PMID: 29739022 [PubMed – as supplied by publisher]

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Retroperitoneoscopic lumbar sympathectomy for plantar hyperhidrosis.

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Retroperitoneoscopic lumbar sympathectomy for plantar hyperhidrosis.

J Vasc Surg. 2017 12;66(6):1806-1813

Authors: Lima SO, de Santana VR, Valido DP, de Andrade RLB, Fontes LM, Leite VHO, Neto JM, Santos JM, Varjão LL, Reis FP

Abstract
OBJECTIVE: The objective of this study was to assess the reduction in quality of life (QoL) caused by the persistence of primary plantar hyperhidrosis (PPH) symptoms and the level of satisfaction in PPH patients after retroperitoneoscopic lumbar sympathectomy (RLS). The efficacy, safety, and procedure of bilateral RLS in both sexes are also described in this study.
METHODS: This is a longitudinal study of consecutive patients who sought specific treatment from a private practitioner for severe PPH as classified on the Hyperhidrosis Disease Severity Scale (HDSS) from October 2005 to October 2014. The patients were asked to report the symptoms of PPH experienced in the immediate preoperative period and to complete a standardized QoL questionnaire developed by de Campos at least 12 months after RLS. Disease outcomes, recurrence of symptoms, and any adverse effects of surgery were evaluated after 30 days and at least 12 months after RLS.
RESULTS: Lumbar sympathectomy was performed 116 times in 58 patients; 30 days after surgery, PPH was resolved in all patients. Three patients (5.2%) reported transient thigh neuralgia, and 19 (32.7%) reported transient paresthesia in the lower limbs. There were no reports of retrograde ejaculation. At a minimum of 12 months after RLS, 49 of the 58 patients had fully and correctly answered the follow-up questionnaire and noted a mild (HDSS 2) to moderate (HDSS 3) increase in pre-existing compensatory sweating. One patient had a PPH relapse within 6 months. Improvement in QoL due to the resolution of PPH was reported in 98% of the 49 patients. None of the operations necessitated a change in the laparotomy approach, and none of the patients died.
CONCLUSIONS: RLS is safe and effective for the treatment of severe PPH in both sexes. There were no reports of retrograde ejaculation after resection of L3 and L4 ganglia. There was a mild to moderate increase in compensatory sweating in about half of the patients, but without any regret or dissatisfaction for having undergone the surgery because of a significant improvement in QoL.

PMID: 29169540 [PubMed – indexed for MEDLINE]

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Recovery of sympathetic nerve function after lumbar sympathectomy is slower in the hind limbs than in the torso.

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Recovery of sympathetic nerve function after lumbar sympathectomy is slower in the hind limbs than in the torso.

Neural Regen Res. 2017 Jul;12(7):1177-1185

Authors: Zheng ZF, Liu YS, Min X, Tang JB, Liu HW, Cheng B

Abstract
Local sympathetic denervation by surgical sympathectomy is used in the treatment of lower limb ulcers and ischemia, but the restoration of cutaneous sympathetic nerve functions is less clear. This study aims to explore the recovery of cutaneous sympathetic functions after bilateral L2-4 sympathectomy. The skin temperature of the left feet, using a point monitoring thermometer, increased intraoperatively after sympathectomy. The cytoplasm of sympathetic neurons contained tyrosine hydroxylase and dopamine β-hydroxylase, visualized by immunofluorescence, indicated the accuracy of sympathectomy. Iodine starch test results suggested that the sweating function of the hind feet plantar skin decreased 2 and 7 weeks after lumbar sympathectomy but had recovered by 3 months. Immunofluorescence and western blot assay results revealed that norepinephrine and dopamine β-hydroxylase expression in the skin from the sacrococcygeal region and hind feet decreased in the sympathectomized group at 2 weeks. Transmission electron microscopy results showed that perinuclear space and axon demyelination in sympathetic cells in the L5 sympathetic trunks were found in the sympathectomized group 3 months after sympathectomy. Although sympathetic denervation occurred in the sacrococcygeal region and hind feet skin 2 weeks after lumbar sympathectomy, the skin functions recovered gradually over 7 weeks to 3 months. In conclusion, sympathetic functional recovery may account for the recurrence of hyperhidrosis after sympathectomy and the normalization of sympathetic nerve trunks after incomplete injury. The recovery of sympathetic nerve function was slower in the limbs than in the torso after bilateral L2-4 sympathectomy.

PMID: 28852403 [PubMed]

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Management of Plantar Hyperhidrosis with Endoscopic Lumbar Sympathectomy.

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Management of Plantar Hyperhidrosis with Endoscopic Lumbar Sympathectomy.

Thorac Surg Clin. 2016 Nov;26(4):465-469

Authors: Rieger R

Abstract
Primary plantar hyperhidrosis is defined as excessive secretion of the sweat glands of the feet and may lead to significant limitations in private and professional lifestyle and reduction of health-related quality of life. Conservative therapy measures usually fail to provide sufficient relieve of symptoms and do not allow long-lasting elimination of hyperhidrosis. Endoscopic lumbar sympathectomy appears to be a safe and effective procedure for eliminating excessive sweating of the feet and improves quality of life of patients with severe plantar hyperhidrosis.

PMID: 27692206 [PubMed – indexed for MEDLINE]

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Plantar Hyperhidrosis: An Overview.

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Plantar Hyperhidrosis: An Overview.

Clin Podiatr Med Surg. 2016 Jul;33(3):441-51

Authors: Vlahovic TC

Abstract
Plantar hyperhidrosis, excessive sweating on the soles of feet, can have a significant impact on patients’ quality of life and emotional well-being. Hyperhidrosis is divided into primary and secondary categories, depending on the cause of the sweating, with plantar hyperhidrosis typically being primary and idiopathic. There is an overall increased risk of cutaneous infection in the presence of hyperhidrosis, including fungal, bacterial, and viral infections. This article discusses a range of treatment options including topical aluminum chloride, iontophoresis, injectable botulinum toxin A, glycopyrrolate, oxybutynin, laser, and endoscopic lumbar sympathectomy. Lifestyle changes regarding hygiene, shoe gear, insoles, and socks are also discussed.

PMID: 27215162 [PubMed – indexed for MEDLINE]

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Plantar hyperhidrosis: A review of current management.

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Plantar hyperhidrosis: A review of current management.

J Dermatolog Treat. 2016 Nov;27(6):556-561

Authors: Singh S, Kaur S, Wilson P

Abstract
AIM: To critically appraise current literature regarding the management of plantar hyperhidrosis in the form of a structured review.
METHOD: A literature search was conducted using various databases and search criteria.
DISCUSSION: The literature reports the use of conservative, medical and surgical treatment modalities for the management of plantar hyperhidrosis. However, long-term follow-up data are rare and some treatment modalities currently available are not fully understood.
CONCLUSION: There is a considerable dearth in the literature on the management of plantar hyperhidrosis. Further study in larger populations with longer follow-up times is critical to access the long-term effects of treatment. Nonetheless, iontophoresis, botulinum toxin injection and lumbar sympathectomy are promising treatment modalities for this disorder.

PMID: 27053510 [PubMed – indexed for MEDLINE]

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Plantar Sweating as an Indicator of Lower Risk of Compensatory Sweating after Thoracic Sympathectomy.

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Plantar Sweating as an Indicator of Lower Risk of Compensatory Sweating after Thoracic Sympathectomy.

Thorac Cardiovasc Surg. 2017 Sep;65(6):479-483

Authors: Kargi AB

Abstract
Background Hyperhidrosis is a dysfunction of the autonomic nervous system that results in regional excessive sweating, mostly in the hands, armpits, and feet. A permanent and effective treatment of hyperhidrosis can be achieved by interruption of the thoracic sympathetic chain with endoscopic thoracic sympathectomy (ETS). However, some side effects, particularly compensatory sweating (CS), are the limitations of this procedure. The mechanism of CS and the associated risk factors are still controversial. The aim of this retrospective study was to determine the relationship with various parameters associated with CS in patients undergoing ETS. Materials and Methods ETS was performed on a total of 95 patients for palmar hyperhidrosis, axillary hyperhidrosis and facial blushing by the same surgeon. The mean age of the patients was 26.41 (± 7) years, and 54 (56.8%) were males. Palmar hyperhidrosis was present in 54 (56.8%) patients, axillary hyperhidrosis in 33 (34.7%) patients, and facial blushing in 8 (8.5%) patients. Moreover, 38 (40%) patients also had plantar sweating. The severity of CS was rated into three scales as less, moderate, and severe. Results Regarding the severity of CS, 55 (57.9%) patients had no or less CS, 28 (29.5%) had moderate CS, and 12 (12.6%) patients had severe CS. Higher age group had a significant increased risk of severe CS (p = 0.03) (r = 0.262). Patients with body mass index (BMI) > 25 kg/m2 had a statistically significantly increased risk of severe CS (p = 0.016). Facial blushing resulted in severe CS in a significantly higher proportion of patients than by palmar and axillary hyperhidrosis (p = 0.001). The level of surgery was another important risk factor for CS, with the T2 level showing an increased risk of severe CS compared with T3 level (p < 0.001). Furthermore, plantar sweating was inversely and significantly related to the development of CS. Patients with plantar sweating had a significantly decreased incidence of developing CS (p = 0.015). Conclusion CS after thoracic sympathectomy for primary hyperhidrosis is the most displeasing and restrictive side effect. This study demonstrates that older age, operation level, facial blushing, and high BMI are risk factors for CS, as have been shown in several similar studies. An interesting finding of the present study is that there was a decreased incidence of CS among patients with plantar sweating. This situation may help us to distinguish high risk for CS before ETS operation.

PMID: 27043786 [PubMed – indexed for MEDLINE]

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[Effect of T4 thoracoscopic sympathectomy on 
plantar hyperhidrosis in patients with 
primary palmoplantar hyperhidrosis].

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[Effect of T4 thoracoscopic sympathectomy on 
plantar hyperhidrosis in patients with 
primary palmoplantar hyperhidrosis].

Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2016 Mar 28;41(3):300-4

Authors: Xiao P, Liu A, Liu W

Abstract
OBJECTIVE: To evaluate the effect of video-assisted thoracoscopic sympathectomy at the T4 level on plantar hyperhidrosis in the treatment of palmoplantar hyperhidrosis.

METHODS: The clinical data of 28 patients with primary palmoplantar hyperhidrosis, who were admited in our hospital from June 2009 to May 2014, was analyzed. All patients were qualified to bilateral thoracoscopic transaction of the sympathetic chain at the thoracic level T4. Patients completed a self-administered hyperhidrosis questionnaire and scoring before and after procedure. Follow-up data were obtained at 1 and 6 months after the surgery.

RESULTS: Endoscopic thoracic sympathectomy at the thoracic level T4 was performed successfully for all cases. Palmar hyperhidrosis was completely alleviated after the operation and no recurrence was observed during follow-up. The ratio for initial improvement of plantar hyperhidrosis was 28.6% (8/28) at 1 month after the surgery followed by a recurrence of plantar hyperhidrosis. No case continued to show the improvement of palmoplantar hyperhidrosis at 6 months after the sympathectomy. Twenty-seven patients (96.4%) were very satisfied with the outcome of the operation, 1 patient (3.6%) satisfied and no patient regretted the surgical procedure.

CONCLUSION: T4 thoracoscopic sympathectomy could initialliy alleviate plantar hyperhidrosis in some patients with palmoplantar hyperhidrosis, but the improvement was not sustained over a long period. It could not be used to treat plantar hyperhidrosis.

PMID: 27033795 [PubMed – indexed for MEDLINE]