Thoracoscopic Sympathectomy

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CHAPTER 28 Thoracoscopic Sympathectomy

Nomenclature

Many terms have been used in different studies to describe the procedure that is performed. Unfortunately, the terminology used in international papers is inconsistent and often leads to confusion. The following glossary has been proposed and corresponds to the diagrams and intraoperative photographs found in the chapter.

R2 sympathectomy or sympathicotomy: division or resection of the chain overlying the second (R2 rib) and third rib (R3). This division accomplishes isolation of the R2 ganglion, which is found in between the two cuts (Figure 28-1). This nomenclature should be used for all subsequent levels; for example, R3 sympathectomy or sympathicotomy means division of the nerve chain over the third and fourth ribs, achieving R3 ganglion isolation.

Video-Assisted Thoracoscopic Sympathectomy

Results

In a series of 396 consecutive procedures (synchronous bilateral in 388 patients, right side alone in 6, left side alone in 1, staged in 1) included 191 (48%) men and 206 (52%) women. The mean age was 29 years (range, 9 to 65 years). Median hospital stay was 0.5 day (range, 0.5 to 3 days). Median follow-up was 2.6 years (range, 2 months to 9 years). The indications were hyperhidrosis in 370 patients, facial blushing in 21, Raynaud’s in 3, digital ischemia in 2, and reflex sympathetic dystrophy in 1 patient. Compensatory sweating occurred in 40% (n = 81 of 202).5

A series of 453 patients showed excellent (74.2%) or good (19.6%) quality of life at 5 years of follow-up.6 In another series of 222 patients, excellent results were reported for more than 90% and compensatory sweating for 85% of patients.7 Results of these two studies suggested that division of the R2 ganglion should be avoided because compensatory sweating developed in 48% of patients when R2 was transected but in only 16% when R2 was not transected. When severe compensatory sweating developed, more than 50% of patients wished that they had not undergone the procedure.

Miller and Force8 described a novel approach to thoracoscopic sympathectomy. They devised a method to screen patients who would be more likely to develop compensatory sweating. They injected the nerve at the planned operative level and reassessed patients after they emerged from anesthesia.8 If the patients benefitted from the injection and did not develop intolerable compensatory sweating, they subsequently underwent sympathectomy.

Tools have been devised to evaluate quality of life (QOL) in terms of objective response, satisfaction, and complications after thoracoscopic sympathectomy. In 1998, Krasna and colleagues proposed a 4-point scoring system of the severity and social impact after thoracoscopic sympathectomy.9 Kwong described a QOL index,10 and Ribas and associates used a standard short-form health survey (SF-36).11 Each of these systems attempts to quantitate the positive and negative results of this procedure for making decisions and assessing costs.

References

1 Kux M. Thoracic endoscopic sympathectomy in palmar and axillary hyperhidrosis. Arch Surg. 1978;113:264-266.

2 Göthberg C., Drott, Claes G. Thoracoscopic sympathicotomy for hyperhidrosis—surgical technique, complications and side effects. Eur J Surg Suppl. 1994;572:51-53.

3 Lin T.S., Huang L.C., Wang N.P., Chang C.C. Video-assisted thoracoscopic T2 sympathetic block by clipping for palmar hyperhidrosis: analysis of 52 cases. J Laparoendosc Adv Surg Tech A. 2001;11:59-62.

4 Wolfer R.S., Krasna M.J., Hasnain J.U., McLaughlin J.S. Hemodynamic effects of carbon dioxide insufflation during thoracoscopy. Ann Thorac Surg. 1994;58:404-408.

5 Kwong K., Krasna M. Clinical experience in 397 consecutive thoracoscopic sympathectomies. Ann Thorac Surg. 2005;80:1063-1066.

6 Milanez de Campos J., Kauffman P., et al. Quality of life, before and after thoracic sympathectomy: report on 378 operated patients. Ann Thorac Surg. 2003;76:886-891.

7 Dewey T.M., Herbert M.A., Hill S.L., et al. One-year follow-up after thoracoscopic sympathectomy for hyperhidrosis: outcomes and consequences. Ann Thorac Surg. 2006;81:1227-1232.

8 Miller D.L., Force S.D. Temporary thoracoscopic sympathetic block for hyperhidrosis. Ann Thorac Surg. 2008;85:1211-1214.

9 Krasna M., Demmy T., McKenna R., Mack M. Thoracoscopic sympathectomy: the U.S. experience. Eur J Surg Suppl. 1998;580:19-21.

10 Krasna M.J., Jiao X., Sonett J., et al. Thoracoscopic sympathectomy. Surg Laparosc Endosc Percutan Tech. 2000;10:314-318.

11 Ribas Milanez de Campos J., Kauffman P., Wolosker N., et al. Axillary hyperhidrosis: T3/T4 versus T4 thoracic sympathectomy in a series of 276 cases. J Laparoendosc Adv Tech A. 2006;16:598-603.

12 Drott C., Claes G., Paszkowski P. Cardiac effects of endoscopic electrocautery of the upper sympathetic chain. Eur J Surg. 1994;572(Suppl):65-70.

13 Kim D.H., Paik H.C., Lee D.Y. Video assisted thoracoscopic re-sympathetic surgery in the treatment of re-sweating hyperhidrosis. Eur J Cardiothorac Surg. 2005;27:741-744.