Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Surgical Treatment of Hyperhidrosis
Hyperhidrosis is a pathologic condition characterized by excessive sweating beyond what is required for normal physiologic thermoregulation. This overproduction causes a significant psychosocial affliction that can negatively affect an individual's quality of life. The incidence of hyperhidrosis depends on the culture, on the climate, and on subjective definitions. Hyperhidrosis affects 1% to 3% of the U.S. population, but this percentage is likely underestimated because of infrequent reporting by patients and incorrect diagnosis by physicians. Hyperhidrosis affects both sexes equally, affects predominantly adolescents or young adults, and can affect multiple body sites. Characteristically, the palmar symptoms start in early childhood, axillary symptoms in adolescence, and craniofacial symptoms in adulthood; puberty usually worsens the symptoms.
Hyperhidrosis is a primary (idiopathic) or secondary disorder with localized or generalized sweating. Focal or primary hyperhidrosis is excessive sweating not associated with a systemic process and usually affects the palms, axillae, or feet. Additionally, some patients may have craniofacial hyperhidrosis, or excessive blushing that is associated with severe emotional, occupational, and social distress. Hyperhidrosis can develop secondary to various medical disorders, such as hyperthyroidism, hypertension, diabetes mellitus, systemic infections, brain lesions, and certain medication use. Systemic medical conditions need to be diagnosed correctly and treated medically and should not be treated with surgery. Also, patients who are overweight (a body mass index > 28) may have full-body or secondary hyperhidrosis.
Eccrine sweat glands are responsible for hyperhidrosis. Eccrine glands are innervated by the sympathetic nervous system but use acetylcholine as the primary neurotransmitter. Thermal sweating is controlled by the hypothalamus, whereas emotional sweating is regulated by the cerebral cortex. A sympathetic signal is carried to sweat glands by cholinergic autonomic neurons. In patients with primary hyperhidrosis, the sweat glands are usually histologically and functionally normal. Although the pathophysiology remains unknown, the cause of hyperhidrosis appears to be an abnormal central response to emotional stress, but it can also occur spontaneously and intermittently. Additionally, there is evidence for a genetic component to hyperhidrosis, and it can be seen in family members. A genetic analysis suggests that an allele for hyperhidrosis may be present in 5% of the population.
There remains significant controversy concerning the optimal surgical therapy for primary hyperhidrosis. That is partially because of the poor definitions of the terms used for both the diagnosis of the problem and the surgical therapy. For example, video-assisted thoracic surgery (VATS) sympathicotomy goes by other names, such as endoscopic thoracic sympathectomy (ETS) or sympathotomy. These terms are not synonymous. Sympathectomy and ganglionectomy refer to total ablation or removal of a segment of the sympathetic chain and ganglia, or both. Sympathicotomy and sympathotomy refer to interruption or simple transection of the sympathetic chain. Sympathetic block refers to a potentially reversible procedure, such as clipping of the sympathetic chain or local anesthetic injections of the nerve. Selective sympathectomy refers to preservation of the sympathetic chain with ramicotomy (division of the rami communicantes). To help clarify these controversies, the Society of Thoracic Surgeons (STS) Task Force on Hyperhidrosis published an expert's consensus paper for the surgical treatment of hyperhidrosis that suggested the adoption of a standard international nomenclature that refers to the rib level (R) instead of the vertebral level at which the nerve is interrupted, how the chain is interrupted, along with systematic pre- and postoperative assessments of sweating pattern, intensity, and quality of life. This report also established specific treatment strategies regarding sympathectomy for distinct patterns of hyperhidrosis.
Nomenclature for Sympathetic Surgery
The International Society on Sympathetic Surgery (ISSS) and the STS Task Force on Hyperhidrosis decided that an internationally agreed upon nomenclature was needed. It has often been unclear exactly where and how a surgeon interrupted the chain, which has made it almost impossible to compare techniques and results. The nomenclature needs to include the location where the sympathetic chain is interrupted and the method of how it is interrupted. Various anatomic landmarks exist to guide the surgeon in determining the exact level where to divide or clip the chain or ganglia for a sympathectomy. The ISSS and STS committees' consensus used a rib-oriented nomenclature. This decision was based on too many patients having mediastinal fat that can obscure clear identification of the specific ganglia and on the multitude of anatomic variations in the ganglion anatomy. The surgeon may add the ganglia that are interrupted to the operative note as well. In addition, the committees agreed that a description of the type of interruption is required denoting whether the chain was clipped, cut, or cauterized or whether a segment was removed.
At operation, therefore, the level is abbreviated as an R3 or an R4 (R referring to rib, and the number referring to which rib). If the chain is clipped on top of the second rib, the abbreviation for the operative note would be “clipped R2, top.” If the chain is cauterized on the top and bottom of the fourth rib, the operative note would be “cauterized, top R4, bottom R4.” Using this standardized nomenclature would allow surgeons worldwide to better communicate with one another.
The literature on sympathectomy for hyperhidrosis must be interpreted cautiously because the definitions can differ from paper to paper. Some studies use objective data such as hand temperature postoperatively to determine success, whereas others simply rely on subjective reporting by the patient. Not all studies assess compensatory hyperhidrosis (CH) similarly, or at the same point postoperatively, or quantify the degree of CH. Standardized preoperative and postoperative questionnaires are needed to objectify the improvement of these patients. One of the best data collection sheets was developed and used by De Campos and associates in an effort to standardize results. Follow-up is a critical part of hyperhidrosis treatment. It is recommended that patients have follow-up appointments or surveys at 1 month, 6 months, 1 year, and annually for at least 5 years if possible.
Patient Selection for VATS Sympathectomy
The ideal candidates for VATS sympathectomy are those who have onset of hyperhidrosis at an early age (usually before 16 years of age), are young at the time of surgery (usually younger than 25 years old), have an appropriate body mass index (<28), report no sweating during sleep, are relatively healthy (no other significant comorbidities), do not have bradycardia (resting heart rate < 55 beats/min), and have no associated body sweating.
Only a small percentage of patients should be considered for surgical treatment. Surgical consultation should include the correct diagnosis of primary hyperhidrosis, the anatomic locations involved, the amount of hyperhidrosis, and full discussion of the surgical options and potential complications. The patients should be made aware that the most satisfied patients are those with palmar or palmar-axillary hyperhidrosis, or both. Finally, patients should also be told of the success and failure rates and long-term results. Physicians can offer the patient the option to discuss the procedure and its side effects with a patient who has already undergone the surgery. This can be done by a conference call under the Health Insurance Portability and Accountability Act (HIPAA) guidelines or face to face at the patient's request.
Prior to any surgical procedure, patients must fail conservative medical therapy. Most insurance companies require a patient to fail at least three nonsurgical treatments. First-line treatment is usually prescription-strength antiperspirants, which work by mechanical obstruction of the eccrine sweat gland ducts or by causing atrophy of the secretory cells. These include antiperspirants with 20% aluminum chloride in ethanol (Drysol) or 6.25% aluminum tetrachloride (Xerac). Drawbacks to using these agents include dyspigmentation of skin, contact dermatitis, and necessity for continuous use. Systematic medication may also be used in the treatment of hyperhidrosis. Anticholinergic agents (glycopyrrolate, propantheline, oxybutynin) are the most commonly used, but the dosage required to reduce sweating causes significant side effects such as dry mouth, blurred vision, and urinary retention. In patients with hyperhidrosis triggered by specific emotional events, beta blockers or benzodiazepines may be useful for reducing the emotional stimulus that leads to excessive sweating. Long-term use of these oral agents is not advisable, and rebound sweating may be more severe with withdrawal of the medication than it is with the baseline hyperhidrosis.
Iontophoresis may be used. It is the introduction of ionized substances through the intact skin by the application of a direct electrical current. Iontophoresis is most often used for palmar or plantar hyperhidrosis; a special axillary electrode can also be used but is less effective. There are limited data from randomized trials, but iontophoresis appears to alleviate symptoms in approximately 85% of patients with palmar or plantar hyperhidrosis. The drawbacks are the upfront machine cost, the labor intensiveness of the treatment, irritation of the skin with scaling and fissuring, and, primarily, the pain associated with the daily treatment sessions.
Botulinum toxin type A (Botox) and type B (Myobloc) have been shown to be effective for axillary and palmar hyperhidrosis, although Botox has not been approved by the Food and Drug Administration (FDA) for palmar treatment. Botox blocks the release of acetylcholine from the presynaptic junction of the autonomic neurons and temporarily reduces sweat production. The effect usually lasts for 3 to 4 months. Long-term results with repeated injections for more than 2 years is infrequent because of antibodies produced against the toxin. Drawback includes pain at the injection sites, transient hand weakness, and high treatment cost.
Surgical therapy is extremely effective for medical refractory primary hyperhidrosis and is based on the interruption of transmission of impulses from the sympathetic ganglia to the sweat glands. Currently, a VATS approach is preferred. The literature on sympathectomy for hyperhidrosis must be interpreted cautiously because of non-uniform definitions of sympathetic chain levels treated, of successful treatment, and of the incidence of post-sympathectomy CH.
Location of Interruption of Sympathetic Chain
Palmar Hyperhidrosis
Opinions differ on how to treat patients who have only palmar hyperhidrosis. For patients who are willing to accept a higher risk of CH because they want their hands to be completely dry, it is suggested that two interruptions in the sympathetic chain be made, at R3 and R4. However, based on a prospective randomized study in 2009 by Liu and associates and a study in 2007 by Yang and colleagues, an R4 alone interruption may be acceptable for these patients because it limits the degree of CH; however, it may lead to moister hands. The patients should be counseled about these differences and should participate in the decision-making process. For these reasons, the top of R3 sympathectomy alone for patients with isolated palmar hyperhidrosis is recommended.
Patients with palmar and plantar hyperhidrosis represent a different challenge. Again, two operations can be performed. An R4 interruption alone may reduce the incidence of CH. Alternatively, an R4 and R5 intervention is a reasonable option; because this intervention results in drier feet, it is the preferred treatment.
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here