Is Clipping Superior to Cauterization in the Treatment of Palmar Hyperhidrosis?

Abstract

Background Endoscopic thoracic sympathectomy has been accepted as the most effective treatment for palmar hyperhidrosis (PH). However, there is a debate regarding the surgical techniques in terms of effectiveness, recurrence, and reversibility. In this study, sympathetic chain disruptions were compared in terms of whether the clipping or ablation technique had an effect on the long-term outcomes of patients who underwent thoracic sympathectomy for primary PH.

Patients and Methods All patients who underwent video-thoracoscopic sympathectomy for PH between May 2008 and October 2011 were included. Single-port bilateral sympathectomy was performed depending on the sweat distribution. As a standard approach, rib-based terminology was used to describe the blockade level of the sympathetic ganglia, and single-level R3 sympathectomy (between R3 and R4) was performed in all patients. The type of sympathectomy was changed. Monopolar electrocautery was first performed and 5-mm clips were then used for nerve disruption. Both techniques were evaluated and compared in terms of effectiveness, reversibility, and recurrence.

Results Cauterization of the sympathetic chain was applied in 28 (47%) (Group A) patients and clipping in 32 (53%) patients (Group B). CH was the most common adverse effect and was observed in 43 (71.6%) patients (Group A, 71.4%; Group B, 71.8%; p = 0.8). The success rate was 93% for Group A and 100% for Group B (p = 0.15). The satisfaction rate for Group A was 83% and for Group B was 86% (p = 0.77). In Group A two patients (7%), and in Group B three patients (9%) requested reversibility because of severe compensatory hyperhidrosis. Overly dry hands were the other most common side effect and were identified in 12 (25%) patients. Recurrences were observed in 11 patients in Group A and 4 patients in Group B (19 vs. 6%; p = 0.01). The mean follow-up time was 33 ± 10.5 months (range, 13–53 months).

Conclusion Both clipping and cauterization are highly effective for the treatment of PH. The methods are comparable in terms of effectiveness and side effects despite the fact that the recurrence rate was higher in the cauterization group. Potential reversibility of compensatory sweating was not observed in our series. Identification of ideal candidates for surgery and education of patients about the permanent side effects of sympathectomy might make these techniques more convenient.

Keywords

thoracoscopy/VATS - quality of life - hyperhidrosis

• References

• 1 Drott C, Claes G. Hyperhidrosis treated by thoracoscopic sympathicotomy. Cardiovasc Surg 1996; 4 (6) 788-790 , discussion 790–791
• 2 Krasna MJ. The role of surgical treatment of hyperhidrosis. Mayo Clin Proc 2011; 86 (8) 717-718
• 3 Lin TS, Fang HY. Transthoracic endoscopic sympathectomy in the treatment of palmar hyperhidrosis—with emphasis on perioperative management (1,360 case analyses). Surg Neurol 1999; 52 (5) 453-457
• 4 Chang YT, Li HP, Lee JY , et al. Treatment of palmar hyperhidrosis: T(4) level compared with T(3) and T(2). Ann Surg 2007; 246 (2) 330-336
• 5 Cerfolio RJ, De Campos JR, Bryant AS , et al. The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg 2011; 91 (5) 1642-1648
• 6 Doolabh N, Horswell S, Williams M , et al. Thoracoscopic sympathectomy for hyperhidrosis: indications and results. Ann Thorac Surg 2004; 77 (2) 410-414 , discussion 414
• 7 Krasna MJ. Thoracoscopic sympathectomy: a standardized approach to therapy for hyperhidrosis. Ann Thorac Surg 2008; 85 (2) S764-S767
• 8 Panhofer P, Zacherl J, Jakesz R, Bischof G, Neumayer C. Improved quality of life after sympathetic block for upper limb hyperhidrosis. Br J Surg 2006; 93 (5) 582-586
• 9 Dewey TM, Herbert MA, Hill SL, Prince SL, Mack MJ. One-year follow-up after thoracoscopic sympathectomy for hyperhidrosis: outcomes and consequences. Ann Thorac Surg 2006; 81 (4) 1227-1232 , discussion 1232–1233
• 10 Li X, Tu YR, Lin M, Lai FC, Chen JF, Miao HW. Minimizing endoscopic thoracic sympathectomy for primary palmar hyperhidrosis: guided by palmar skin temperature and laser Doppler blood flow. Ann Thorac Surg 2009; 87 (2) 427-431
• 11 Sugimura H, Spratt EH, Compeau CG, Kattail D, Shargall Y. Thoracoscopic sympathetic clipping for hyperhidrosis: long-term results and reversibility. J Thorac Cardiovasc Surg 2009; 137 (6) 1370-1376 , discussion 1376–1377
• 12 Kopelman D, Hashmonai M. The correlation between the method of sympathetic ablation for palmar hyperhidrosis and the occurrence of compensatory hyperhidrosis: a review. World J Surg 2008; 32 (11) 2343-2356
• 13 Vanderhelst E, De Keukeleire T, Verbanck S, Vincken W, Noppen M. Quality of life and patient satisfaction after video-assisted thoracic sympathicolysis for essential hyperhidrosis: a follow-up of 138 patients. J Laparoendosc Adv Surg Tech A 2011; 21 (10) 905-909
• 14 Reisfeld R. Sympathectomy for hyperhidrosis: should we place the clamps at T2-T3 or T3-T4?. Clin Auton Res 2006; 16 (6) 384-389
• 15 Loscertales J, Congregado M, Jimenez-Merchan R , et al. Sympathetic chain clipping for hyperhidrosis is not a reversible procedure. Surg Endosc 2012; 26 (5) 1258-1263
• 16 Candas F, Gorur R, Haholu A , et al. The effects of clipping on thoracic sympathetic nerve in rabbits: early and late histopathological findings. Thorac Cardiovasc Surg 2012; 60 (4) 280-284
• 17 Telaranta T. Secondary sympathetic chain reconstruction after endoscopic thoracic sympathicotomy. Eur J Surg Suppl 1998; (580) 17-18
• 18 Fibla JJ, Molins L, Mier JM, Vidal G. Effectiveness of sympathetic block by clipping in the treatment of hyperhidrosis and facial blushing. Interact Cardiovasc Thorac Surg 2009; 9 (6) 970-972
• 19 Lin CC, Telaranta T. Lin-Telaranta classification: the importance of different procedures for different indications in sympathetic surgery. Ann Chir Gynaecol 2001; 90 (3) 161-166
• 20 Rodríguez PM, Freixinet JL, Hussein M , et al. Side effects, complications and outcome of thoracoscopic sympathectomy for palmar and axillary hyperhidrosis in 406 patients. Eur J Cardiothorac Surg 2008; 34 (3) 514-519