CASE STUDY 1
The patient was a 23-year-old female who had immigrated to Ireland for work from Eastern Europe. She worked as a research and development officer in a large medical device company and her job required fine motor skills to deal with very delicate machinery. Due to the symptomatic hyperhidrosis, she needed to wear gloves at all times during work, which compromised her performance. This was on top of her social-related concerns. She had suffered from symptomatic hyperhidrosis on her palms and axillas all her life.
During her earlier years, despite visiting multiple doctors, she was not referred for treatment. Upon arrival to Ireland, she was referred by her GP for non-invasive treatment as an initial treatment strategy. She underwent botox treatment for six months. While this improved her symptoms dramatically, it was short-lived and the patient did not experience prolonged alleviation of symptoms. She enquired about a longer solution such as surgery and was referred to the corresponding author.
Following an extensive informed consent process, the patient underwent surgical treatment by VATS sympathectomy. This was performed by a two-port VATS approach as delineated in this article. As the targeted area was the palms and axillas, the author performed a standard sympathectomy of the T3 and T4 ganglia. The procedure was uneventful and the patient was discharged on the same evening.
Post-operatively, the patient developed a mild degree of compensatory hyperhidrosis on the back of her thighs bilaterally, which was reported at the one-week review. The patient did not have any other complications. Her palms and axillas were completely dry post-operatively. The patient was very satisfied with the results, was able to continue her work well, and remained in Ireland.
CASE STUDY 2
In this case, a 34-year-old teacher presented to her GP requesting VATS sympathectomy. This patient had been suffering from sweating in her palms and most importantly suffered from severe facial blushing. The condition severely interfered with her ability to teach and present her work in meetings.
She was prescribed beta blockers for six months and was diligently compliant. While this reduced her symptoms, it did not ameliorate them, and the patient also found the medication intolerable due to fatigue.
Following a period of online searching, she requested to be referred for VATS sympathectomy and was referred to the author.
The patient subsequently underwent bilateral VATS sympathectomy of the T2 and T3 ganglia to specifically target her facial blushing. The surgery was uneventful and the patient was discharged on the same day.
At the four-week post-operative review, the patient reported immediate relief of her facial blushing. She did not report any complication. She discontinued beta blockers and continued successfully in her teaching job.
Sweating is a natural physiological reaction to regulate core body temperature in response to physiological and emotional stress. The thermoregulatory centre in the brain mediates this response via sympathetic innervation to the cholinergic receptors of the eccrine sweat gland.
Hyperhidrosis is a disorder of excessive sweating due to the overstimulation of the sympathetic system, leading to excessive release of acetylcholine, overstimulating the cholinergic receptors. The acetylcholine negative feedback loop that usually stops this phenomenon is thought to be impaired in individuals suffering from this condition.
Hyperhidrosis is believed to affect around 3 per cent of the population and is most common in individuals between 20-to-60 years of age, with a tendency to begin below 25 years. There is no known gender preponderance with the condition, affecting both males and females equally. The excessive sweating usually occurs in the palmar area, followed by the axilla and the plantar area. In certain individuals, this can also manifest as facial blushing.
FIGURE 1: Anatomical location of thoracic sympathetic chain and ganglia
Diagnosis
Hyperhidrosis can be primary with no known cause, or secondary to a medical condition. Diagnostic criteria for primary hyperhidrosis include:
- Excessive sweating for six or more months;
- Sweating involving axilla, palms, soles, and/or face;
- Sweating is bilateral and symmetrical;
- Decreased or no sweating at night;
- Sweating episodes last at least seven days;
- The individual is 25 years of age or younger,
- There is a family history,
- Sweating impairs daily living activities.
Secondary associated medical conditions include:
- Thyrotoxicosis;
- Neuropathy;
- Hypoglycaemia;
- Pheochromocytoma;
- Menopause;
- Lymphoma;
- Tuberculosis;
- Alcohol abuse disorder.
Treatment options
- Medication (beta blockers);
- Iontophoresis;
- Botox;
- Surgical sympathectomy.
Surgical treatment of hyperhidrosis
As hyperhidrosis is principally caused by over stimulation of the sympathetic nervous system, surgery for this condition involves interrupting the sympathetic chain. This is known as sympathectomy. In the current era, this procedure is performed via a video assisted thoracoscopic (VATS) approach.
In the author’s institution, it is performed via a two port (two incisions) VATS approach. In some institutions, this is performed with more ports and even a larger utility or working port for ease of conducting the procedure. This is mainly down to availability of instruments, the individual surgeon’s or institutional experience and preference.
In the author’s institution, VATS sympathectomy is performed as a day case procedure. The patient is admitted on the morning of surgery, fasting from the previous night. Following administration of general anaesthesia and single lung ventilation, the patient is positioned supine with elevation of the back using a sandbag, and the arm is abducted to 90 degrees to expose the mid axillary line. Then, two 5mm stab incisions are made to facilitate a videoscope and a ‘hook’ diathermy dissector.
Sometimes, if required, an endoscopic ‘peanut dissector’ can also be introduced via the instrument port to depress the lung. Upon entry to the thoracic cavity, carbon dioxide insufflation is used to depress the lung and expose the sympathetic chain. The sympathetic chain and its corresponding ganglia level is identified carefully.
This is an important step as inadvertent ablation of the stellate ganglia could result in Horner syndrome (ptosis of the eyelid, miosis, and anhidrosis), which is a devastating complication for a benign procedure. It is also important to identify surrounding vascular structures as damage to vascular structures leading to bleeding could be difficult to control thoracoscopically, leading to the need for thoracotomy.
Once identification of the sympathetic chain and surrounding structures is completed, the sympathectomy procedure begins. Using a ‘hook diathermy’ device, the parietal pleura overlying the sympathetic chain is opened to visualise the ganglia directly. Then, the sympathetic chain and ganglia is dissected free. A number of techniques for sympathectomy then can be performed, including:
1. Ganglionectomy – direct ablation of the ganglion to disconnect it;
2. Clipping with metal clip;
3. Complete removal of the required sympathetic chain.
Both clipping and ganglionectomy have the advantage of being quicker to perform and are more selective, with less thermal damage to the surrounding structures, and therefore, lower complication rates. Clipping has the advantage of being reversible, especially if compensatory hyperhidrosis becomes troublesome. Whereas complete removal of the required sympathetic chain ensures higher success rates of improving hyperhidrosis.
Complications of the procedure include:
General complications of VATS surgery may occur, including wound pain, infection, bleeding, anaesthesia complication, etc. Specific complications of VATS sympathetectomy include:
- Compensatory hyperhidrosis – this is where targeted areas, ie, axilla and palm or plantar area, are dry from sweat; however, hyperhidrosis is transferred to other areas, usually the truncal areas and the thighs.
- Horner’s syndrome – this is when the stellate ganglia is inadvertently damaged leading to ptosis (drooping of eyelids), miosis (small pupils), and anhidrosis.
- Bradycardia.
New indication for VATS sympathectomy
As mentioned previously, one of the complications of sympathectomy is bradycardia. This principle was applied in a selective group of patients with a condition known as syndrome of inappropriate sinus tachycardia. This is a new indication for VATS sympathectomy, which is gaining evidence and popularity among the cardiac electrophysiology field. However, more data is required to ascertain this technique.
References on request
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