Asian Cardiovasc Thorac Ann 1999;7:56-58
© 1999 Asia Publishing EXchange Pte Ltd
Reoperation for Essential Hyperhidrosis
Yoon Yong Han, MD,
Lee Doo Yun, MD,
Kim Hae Kyoon, MD,
Cho Hyun Min, MD
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Department of Thoracic & Cardiovascular Surgery Yongdong Severance Hospital Seoul, Korea (South)
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For reprint information contact: Lee Doo Yun, MD Tel: 82 2 3497 3380 Fax: 82 2 3461 8282 email: dylee{at}yumc.yonsei.ac.kr Department of Thoracic & Cardiovascular Surgery, Respiratory Center, Yongdong Severance Hospital, Yonsei College of Medicine, 146-92 Dokuk-dong, Kangnam-gu, Seoul, Korea.
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Abstract
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Palmar hyperhidrosis has a recurrence rate of 0% to 5% after thoracic sympathectomy. From January 1992 to October 1997, thoracic sympathectomy was performed by video-assisted thoracoscopic surgery for hyperhidrosis in 490 patients of whom 5 (2 male and 3 female with a mean age of 20 years) experienced recurrent hyperhidrosis in the early (< 7 days) or late (up to 6 months) postoperative period. All patients had moderate to severe pleural adhesions in the previous sympathectomy sites but no operative complications or crossover to thoracotomy occurred. Surgery resulted in satisfactory outcomes showing that video-assisted thoracoscopic sympathectomy was effective in treating recurrent hyperhidrosis. Prevention of recurrence requires the identification and resection of the second thoracic sympathetic ganglion as well as the Kuntz fibers.
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Introduction
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The choice of treatment for palmar hyperhidrosis is thoracic sympathectomy although it is associated with a recurrence rate of up to 5% in the immediate postoperative period or later in the follow-up.1–6 Late recurrence is usually noted between 2 to 18 months postoperatively but it may occur many years later. Currently, the treatment of choice for relapse is repeat thoracic sympathectomy.6–9 The cause of recurrent hyperhidrosis after sympathectomy can be either incomplete resection of the sympathetic chain or the presence of Kuntz fibers and axonal regrowth of the sympathetic chain. The aim of this study was to investigate the cause of recurrent hyperhidrosis after sympathectomy and to assess the effectiveness of video-assisted thoracoscopic sympathectomy in treating the relapse.
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Patients and Methods
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From January 1992 to March 1997, 490 patients underwent sympathectomy for facial or palmar hyperhidrosis by video-assisted thoracoscopic surgery (VATS) at Yondong Severance Hospital. Five of these patients experienced a recurrence of hyperhidrosis and underwent a second VATS sympathectomy procedure. There were 3 male and 2 female patients ranging in age from 15 to 24 years (mean, 20 years). In 3 patients, treatment failure occurred in the immediate postoperative period (1 to 7 days) whereas in the other 2, palmar and facial hyperhidrosis reappeared several months later (Table 1
). The patients had received either unilateral or bilateral sympathectomy by VATS (Table 1). Although there were moderate to severe pleural adhesions from the previous sympathectomies, reoperation was performed in all patients by VATS without concomitant thoracotomy. With the patient in the lateral decubitus position, the overlying pleural adhesions were carefully dissected followed by resection of the sympathetic ganglion using video-assisted thoracoscopy. In one patient, difficulty in visualizing the sympathetic ganglion due to pleural adhesions necessitated obtaining a frozen biopsy to confirm the ganglionic neural tissue. Follow-up was complete for these 5 patients with a mean duration of follow-up of 6 months (range, 1 to 12 months).
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Results
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The operation time was 90 minutes for the bilateral procedure and the mean operation time for the 4 cases of unilateral sympathectomy was 77 minutes (range, 50 to 90 minutes). The 3 patients who had experienced early recurrence of symptoms were found to have received incomplete resection of the sympathetic chain at the first procedure. In the 2 patients whose hyperhidrosis recurred several months after the first procedure, the cause could not be confirmed but it appeared to be due to regeneration of a side branch of the sympathetic nerve. In all patients, the chest tube was safely removed within 2 days postoperatively. The hospital stay ranged from 1 to 4 days with a mean duration of 2.5 days. Surgery resulted in immediate postoperative symptomatic relief that continued throughout the ensuing months of follow-up in all patients.
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Discussion
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Hyperhidrosis is a disease of the autonomic nervous system and the eccrine glands. It is caused by excessive secretion of the exocrine gland that is innervated by the cholinergic fibers of the sympathetic ganglion. In primary hyperhidrosis, excessive sweating is usually noted in the palmar or plantar areas or the axillae. A variety of treatments such as sedatives, anticholinergic drugs, calcium channel blockers, beta-adrenergic antagonists, and iontophoresis has been used but all are associated with a high incidence of complications and recurrence. Since the development of video-assisted, thoracic sympathectomy has emerged as a good option for the treatment of primary hyperhidrosis. This is now the method of choice due to a low complication rate and excellent postoperative recovery. Recurrence rates varying from 0% to 5% after thoracic sympathectomy have been reported.1–6 In our institution, recurrence of hyperhidrosis after video-assisted thoracic sympathectomy was observed in only 5 among 490 patients, giving an overall recurrence rate of 1%.
In 4 of these patients, recurrence was experienced only on the right side but we were unable to identify a factor that might predispose to right-side recurrence. The causes of recurrent hyperhidrosis after sympathectomy by VATS are reported to be multifactorial and include an incomplete sympathetic nerve at the origin of the sympathetic nerve, encountered in 20% of patients in whom the sympathetic nerve originates from the first thoracic sympathetic ganglion (inferior to the stellate ganglion), bypassing the sympathetic ganglion by the Kuntz fiber and connecting to the brachial plexus, as well as local regeneration of the resected nerve.10–13
To prevent recurrence, detection and accurate localization of the second sympathetic ganglion, confirmation of anatomic variations of the accessory nerve, the accessory ganglion, and the Kuntz fibers, as well as resection of a broad margin of 3 to 5 cm around the second sympathetic ganglion is necessary.14,15 The adequacy of the sympathectomy can be monitored by measuring bilateral palmar surface temperatures or by measuring plethysmographic blood flow.16 When symptoms recur after thoracic sympathectomy, especially during the immediate postoperative period, reoperation for resection of the sympathetic ganglion produces the best results.16–19
From this study, it was observed that immediate postoperative satisfactory results were not always sustained over time. Therefore, patients should be informed of the possibility of symptomatic relapse both in the immediate and late postoperative period, consisting of compensatory, gustatory, and phantom hyperhidrosis. Knowledge of the normal and anatomical variations of the thoracic sympathetic ganglion is essential to achieve good long-term results. We recommend reoperation by VATS as the treatment for recurrent hyperhidrosis.
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References
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Abstract
Introduction
