Surg Endosc (2007)
DOI: 10.1007/s00464-007-9241-9
Ó Springer Science+Business Media, LLC 2007
Comparing T2 and T2–T3 ablation in thoracoscopic
sympathectomy for palmar hyperhidrosis: a randomized
control trial
A. N. Katara, J. P. Domino, W.-K. Cheah, J. B. So, C. Ning, D. Lomanto
Minimally Invasive Surgical Centre, Department of General Surgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074
Received: 13 October 2006/Accepted: 2 November 2006
Abstract
Background: Thoracoscopic sympathectomy is a useful
therapeutic option for palmar hyperhidrosis. Surgeons
diﬀer in the level of the sympathetic chain ablated. This
study aimed to compare the blockade of the T2 with
levels T2 and T3 to verify the eﬀectiveness of diﬀerent
ablation levels in relieving hyperhidrosis symptoms.
Methods: For patients undergoing bilateral thoracoscopic sympathectomy for palmar hyperhidrosis, T2–T3
ablation is performed bilaterally. In our series, 25 consecutive patients were blindly randomized to undergo
unilateral T2 and T3 ablation followed by contralateral
ablation of level T2 only. The patients were followed up
and analyzed for comparison of symptoms bilaterally,
compensatory hyperhidrosis, and levels of satisfaction
postoperatively.
Results: The study group consisted of 25 patients with a
male:female ratio of 3:2 and a mean age of 32 years
(range, 19–50 years). The mean operative time was 35
min. The patients were followed up for a mean period of
23 months (range, 2–65 months). All 25 patients conﬁrmed that their palmar sweating resolved postoperatively, with both palms equally dry. Of the 25 patients,
20 (80%) complained of compensatory hyperhidrosis,
which also was bilaterally symmetric. The areas involved
were trunk (80%), lower limbs (32%), and armpits
(12%). Overall, 80% of the patients were very satisﬁed
with the procedure. The remaining 20% experienced
mild to moderate compensatory hyperhidrosis, which
did not seem to aﬀect their lifestyle.
Conclusion: The ﬁndings show that T2 ablation in thoracoscopic sympathectomy for palmar hyperhidrosis is
as eﬀective as T2–T3 ablation in terms of symptomatic
relief, recurrence, compensatory hyperhidrosis, and patient satisfaction.
Key words: Hyperhidrosis — Sweaty palms — Sympathectomy — Thoracoscopy
Surgical management of palmar hyperhidrosis involves
blockade of the thoracic sympathetic chain. Several
approaches have been used in the past to access the
thoracic sympathetic ganglia, namely, supraclavicular,
axillary, and thoracic (anterior or posterior) procedures.
These procedures were associated with diﬃcult access,
technical diﬃculty, comorbidity, and potentially hazardous complication.
The ﬁrst attempts at endoscopic thoracic sympathectomy (ETS) were by Kux [12] in 1940, Hughes [10]
in 1942, and Hukkei [11] in 1958 in Japan using direct
vision scopes. In 1990, ETS was performed using videoassisted thoracic surgery [18]. This technique has become popular because of the reduced morbidity and
mortality and the beneﬁts of minimally invasive surgery
oﬀered to the patients. These beneﬁts include reduced
postoperative pain, shorter hospitalization, earlier
recovery and return to work, and fewer complications.
Furthermore, both sides can be treated in the same sitting, thus avoiding readmission for a second procedure
in bilateral cases. Besides hyperhidrosis, sympathectomy
also is successfully performed for other indications such
as BuergerÕs disease, RaynaudÕs syndrome, severe
intractable pain of ischemic ulcers in the arm [20], reﬂex
sympathetic dystrophy, and long QT syndrome [13].
Surgeons diﬀer in the level of the sympathetic nerves
ablated. Our aim was to compare the blockade of the
second thoracic sympathetic ganglion (T2) with ablation
of levels T2 and T3 to verify the eﬀectiveness of diﬀerent
ablations on symptoms of hyperhidrosis.
Materials and methods
Correspondence to: A. N. Katara
Our usual surgical practice for palmar hyperhidrosis is to ablate the T2
and T3 sympathetic ganglia bilaterally. We randomized 25 consecutive
Table 1. Follow-up questionnaire
Question
Response
1. Symptoms
a. Have your preoperative symptoms of excessive sweating resolved?
b. If not, when did they return?
c. Is one side drier than the other?
2. Compensatory sweating
a. Do you have excessive sweating in other areas of your body?
b. If so, which parts are aﬀected?
c. If so, is it more on any one side of the body?
d. What is its severity?
e. Does it aﬀect your daily lifestyle?
f. What is its trend?
3. Satisfaction
How would you rate your satisfaction with the result of the operation?
a. I would have the operation again; I have no side eﬀects.
b. I would have the operation again; side eﬀects, if any, do not disrupt quality of life.
c. I probably would not have the operation again; results are unsatisfactory and/or side
eﬀects aﬀect the quality of life.
d. I deﬁnitely would not have the operation again; results are insuﬃcient and/or side
eﬀects severely aﬀect the quality of life.
Table 2. Patient characteristics
Study group
Age: years (range)
Sex: M:F
Degree of symptoms: n (%)
Mild
Moderate
Severe
Yes/no _____ days/months
Right/left/equal
Yes/no
Trunk/axilla/lower limbs/others____________
Right/left/equal
Mild/moderate/severe
Yes/no
Same/increased/reduced
Very satisﬁed
Satisﬁed
Dissatisﬁed
Very dissatisﬁed
Table 3. Operative details
25
32 (19–50)
3:2
0 (0)
4 (16)
21 (84)
patients to undergo unilateral T2 and T3 ablation followed by contralateral blockade of T2 only. The side undergoing ablation at levels
T2 or T2–T3 was randomized by a ‘‘closed envelope’’ method. All the
patients were adequately worked up preoperatively to exclude secondary hyperhidrosis including hyperthyroidism, chronic infections,
malignancy, and immunologic disorders. The patients also were assessed for the degree of symptoms (subjectively mild, moderate, or
severe), the side aﬀected, and hyperhidrosis in other areas. The patients
with generalized hyperhidrosis or excess sweating aﬀecting other areas
of the body, such as the axilla or the feet, were excluded from the
study.
The ETS procedure was performed with the patient under
general anesthesia using single-lung ventilation via a double-lumen
endotracheal tube. Our patient positioning was diﬀerent from most
described techniques, which adopt a lateral position, with the need
to change positions before the opposite side is tackled. Instead, our
patients were positioned supine with both arms abducted at right
angles. A sandbag was placed under the shoulder blades to elevate
the axilla from the table. One lung was deﬂated, and a 3-mm port
was introduced in the thorax along the midaxillary line in the third
intercostal space. A 3-mm telescope was introduced into the thorax
through the ﬁrst port, and 1 l of carbon dioxide was insuﬄated at
low pressures (7–8 mm Hg).
Adequate deﬂation and collapse of the lung were conﬁrmed before
the introduction of the second port (1.6 mm) under vision in the same
intercostal space along the anterior axillary line. The second and third
ribs were identiﬁed, and the thoracic sympathetic ganglia were delineated in their relation. The T2 and T3 ganglia then were ablated using
monopolar diathermy, with a ballpoint scalpel used to sever the nerves.
Care was taken to avoid the intercostal and azygous veins in the
vicinity. Any aberrant nerve pathways (Kuntz ﬁber) were sought and
ablated if present.
Next, 1 ml of a local anesthetic agent (0.5% bupivacaine) was
inﬁltrated along each of the cut nerve endings. Hemostasis was conﬁrmed, and the ports were removed under vision after full inﬂation of
the lung was conﬁrmed. The skin incisions at the port sites were sealed
with glue (Dermabond; Johnson & Johnson, New Brunswick, NJ,
T2–T3 (right), T2 (left): n (%)
T2 (right), T2–T3 (left): n (%)
Mean operating time: min (range)
Mean rise of probe temperature: °C (range)
Intraoperative complications
Bleeding
Lung injury
Pneumothorax (immediately postop)
14 (56)
11 (44)
35 (15–50)
1.4 (0.8–1.9)
0
0
0
postop, postoperatively
USA). Conﬁrmation of the sympathetic blockade was documented by
an immediate rise in the temperature of the upper limb (>1°C)
through a thermoprobe taped on the patientÕs palm. The same procedure then was performed on the contralateral side, but only the T2
sympathetic ganglion was diathermized. A postoperative chest x-ray
was taken in search of lung inﬂation and to rule out the presence of
residual pneumothorax.
The patients were postoperatively analyzed for comparison of
symptoms bilaterally, compensatory hyperhidrosis, and levels of satisfaction. The patients were subsequently interviewed at follow-up
assessment (Table 1) by a blinded observer.
For this condition, T2 or T2–T3 ablation both are standard accepted methods of treatment. Hence, no special permission from the
ethics committee was needed. The purpose of this study was explained
to the patients, and all the participants willingly consented to enroll for
the trial. All the statistics were calculated using SPSS software (SPSS
Inc., Chicago, IL, USA).
Results
The study group consisted of 25 patients with a male:female ratio of 3:2 (Table 2). and a mean age of 32
years (range, 19–50 years). Moderate hyperhidrosis was
reported by the patients, and the symptoms were severe
for 84%. The side for T2 or T2–T3 ablation was randomly selected, with 56% undergoing two-level ablation
on the right and 44% undergoing the procedure on the
left.
Our average operative time was 35 min (Table 3).
The time was calculated from the time of skin incision to
Table 4. Postoperative surveillance
Mean follow-up period: months (range)
Symptoms of palmar hyperhidrosis: n (%)
Patients with resolution of symptoms: n (%)
Immediate post-op resolution: n (%)
Bilaterally symmetrical
Compensatory sweating
No. of patients: n (%)
Severity: n (%)
Mild
Moderate
Severe
Areas involved: %
Axilla
Trunk
Lower limbs
Bilaterally symmetric: n (%)
Satisfaction: n (%)
Very Satisﬁed
Satisﬁed
Dissatisﬁed
Very dissatisﬁed
23
25
25
25
(2–65)
(100)
(100)
(100)
20 (80)
15 (60)
5 (20)
0
12
80
32
20 (100)
20 (80)
5 (20)
0
0
the application of the dressing over the wound. This
excluded anesthesia induction and reversal time.
The average rise in probe temperature after the nerve
ablation was 1.4°C. This usually occurred 2 to 5 min
after the ablation. No clinically signiﬁcant pneumothorax was recalled postoperatively.
The postoperative surveillance is summarized in Table 4. The patients were followed up for mean period of 23
months (range, 2–65 months). All 25 patients conﬁrmed
that their palmar sweating resolved postoperatively, with
both palms equally dry. Of the 25 patients, 20 (80%) reported compensatory sweating in other parts of the body,
which also was bilaterally symmetric. The areas involved
were the trunk (80%), lower limbs (32%), and armpits
(12%). Overall, 80% were very satisﬁed with the procedure
(mild or no sweating), and 20% were satisﬁed with moderate compensatory sweating not aﬀecting their lifestyle.
None were dissatisﬁed with the procedure. There was no
bleeding, lung injury, or residual hyperhidrosis in our
study group.
Discussion
Primary palmar hyperhidrosis is a condition characterized by oversecretion of the eccrine sweat glands of
unknown etiology, resulting in heavy sweating in the
palms. The sweating is characteristically disproportionate to that required for thermoregulation and dissipation of body heat [13]. Usually aggravated by
emotional factors or heat, it is considered a disposition
rather than a disease. It aﬀects 0.6% to 1% of the
population [12]. Patients with palmar hyperhidrosis are
distressed with cold and wet hands, which is not only
uncomfortable, but often embarrassing as well, both
socially and professionally. Because of its non–lifethreatening nature, the condition often is treated using
nonsurgical methods, with poor results. The high
morbidity and potential mortality of a thoracotomy for
sympathetic blockade makes it an unpopular procedure
for hyperhidrosis.
The advent of safe and easy video-assisted thoracoscopic techniques has lowered the threshold for oﬀering
ETS as a surgical option to patients with moderate to
severe hand sweating, with good results. The use of
needlescopic ports and instruments makes this procedure aesthetically acceptable [5]. In addition, it oﬀers all
the beneﬁts of a minimally invasive procedure.
Diﬀerent techniques have been described for videoassisted thoracic surgery to relieve sweaty palms. These
techniques diﬀer in the levels of sympathetic nerve
blockade, with controversial results in terms of eﬃcacy
and side eﬀects. Most techniques favor blockade of
levels T2, T3, and even T4. Blockade of T4 (or even T5)
is recommended for axillary hyperhidrosis. The Japanese Society of Thoracoscopic Sympathetic Surgery
recommends ablation at levels T3 and T4 (sometimes
extending to the lower half of T2) for palmar and level
T5 for axillary hyperhidrosis [20]. Blockade of multiple
lower levels is associated with higher incidences of
compensatory hyperhidrosis [2, 4, 5, 7, 9, 14, 16, 19 ,22].
In our study, the results showed that T2 blockade is as
eﬀective as T2–T3 ablation for relief of palmar hyperhidrosis, with the same incidence of side eﬀects (i.e.,
pneumothorax, compensatory hyperhidrosis, and relapse).
Most studies describe the procedure in the lateral
position, which requires the repositioning of the patient
for performance of the procedure bilaterally. This
exercise is cumbersome and inconvenient, and it also
increases the operative time. In our experience, a supine
position with a slight reverse Trendelenburg position
gives adequate visualization of the ﬁrst three sympathetic ganglia and eﬀectively reduces the operative time
(our average operative time was 35 min) without
increasing the risk of complications.
Several options are available for blockade of the
sympathetic trunk including resection, electrocoagulation, cryocoagulation, harmonic scalpel, radiofrequency, laser, or interruption with titanium clips [13]. There
is no evidence that one technique is superior to another, and our preferred technique is ablation of
the ganglia by monopolar electrodiathermy ballpoint
scalpel.
Symptoms of palmar hyperhidrosis usually resolve
immediately postoperatively, and patients can conﬁrm
this in the recovery room. Persistence of symptoms can
be attributable to various reasons such as mistaken
identiﬁcation of the sympathetic levels, incomplete
ablation, accessory nerve pathways (Kuntz ﬁbers),
nerve regeneration, or innervation by the stellate ganglion. Recurrence of symptoms usually occurs within 1
year of surgery [17] at a rate of 0% to 16% according
to diﬀerent reviews [21]. In our experience, symptoms
of palmar hyperhidrosis resolved in all patients, with
no recurrence reported after 23 months of follow-up
evaluation.
Compensatory sweating, a reﬂex hyperhidrosis, is
reported in 5% to 85% [13] of patients subjected to
thoracoscopic sympathectomy, as reported in diﬀerent
literature reviews. It depends on climatic conditions and
emotional stress and is higher in warm and humid
locations. Some authors even suggest preservation of the
sympathetic trunk and selective blockade of the communicating branches and postganglionic ﬁbers (Wittmoser procedure) [7].
In our series, we reported a compensatory hyperhidrosis in 80% of our patients, which was tolerable and
did not seem to aﬀect their lifestyle. All the patients were
satisﬁed. These patients showed resolution of symptoms
on both sides, irrespective of whether only T2 or both
T2 and T3 were ablated. Improvement of symptoms in
these patients was bilaterally symmetric.
A small insigniﬁcant pneumothorax can be expected
after ETS in about 75% of cases [15], which gets spontaneously absorbed, usually within 24 h. The incidence
of pneumothorax requiring chest drainage is 0.4% to
2.3% [7, 8]. Hemothorax may occur because of bleeding
from the intercostal veins or the azygous veins, which
may lie in close proximity to the sympathetic trunk. This
may require intercostal drainage or even reoperation,
depending on its severity.
In our series, although we used a supine position
with needlescopic ports, we did not observe an increased
risk of postoperative pneumothorax or intraoperative
complications, which was nil for both.
In conclusion, our study suggests that T2 ablation in
thoracoscopic sympathectomy for palmar hyperhidrosis
is as eﬀective as ablation of levels T2 and T3 in terms of
outcome, recurrence, compensatory hyperhidrosis, as
well as levels of satisfaction. Although we had a limited
number of cases and need to randomize a larger study
group to substantiate our results, no diﬀerence has been
observed between the two levels of ablation. This is in
accordance with other studies, in which no diﬀerence
was reported in terms of patient satisfaction, compensatory hyperhidrosis, and recurrence.
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