Dr Arun Prasad, MS, FRCS, FRCSEd Senior Consultant, Surgeon, Minimal Access Surgery, Apollo Hospital, New Delhi, India
Email: firstname.lastname@example.org Tel: ++91-11-29871280 /1202 Mobile No. ++91-9811082425
At New Delhi, India, Minimal Access/ Minimally Invasive Surgery, Thoracoscopic Surgery, VATS (Video Assisted Thoracic Surgery), and ETS (Endoscopic Thoracic Sympathectomy) are terms used to describe the modality of procedure that is done to interrupt the sympathetic nerve chain as a treatment for Hyperhidrosis of face, palms and axilla (arm pits).
Following is a brief introduction of the disease, treatment options and views of some of the experienced surgeons around the world. I hope it answers most of the questions. If there are any unanswered questions or doubts, please email to me at email@example.com .
Warning!! Please note that the management of this disease is complicated and should be carefully planned with an expert.
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Hyperhidrosis, is sweating in excess of that required for normal thermoregulation. It is a condition that usually begins in either childhood or adolescence. Although any site on the body can be affected, the sites most commonly affected are the palms, soles, and axillae.
The condition often causes great emotional distress and occupational disability for the patient, regardless of the form. There is very little awareness of this problem and hence it leaves the patient totally baffled. Parents, friends, teachers, colleagues and often doctors think that it is because the person is " nervous " and as time passes, the person also starts believing the same. It leads to lack of confidence, isolation, introversion, shyness, non-sporty personality etc. It is important to note that these behavioral changes are a result of the sweating and NOT the cause of it.
It is unfortunate that so many people ( 1: 1000 as per a US survey ) who can be cured of this dreadful problem are suffering from it simply because of lack of awareness amongst public and even doctors.
The following are the common problems faced by my patients who have come to me for treatment
Inability to shake hands with clients, seniors, colleagues leading to embarrassing start of a meeting and awareness of this prevents them from confidently dealing with people.
Key board and mouse getting wet while using computer for professional reasons. ( Also camera, sport racket, mechanical instruments etc)
Wetting of answer sheets during exam.
Reluctant to get married.
Severe cases of hyperhidrosis may adversely affect the patient's quality of life by causing great emotional distress, social embarrassment, and work-related disability (due to palmoplantar hyperhidrosis).
Palmoplantar sweating may result in irritation of the affected skin, ultimately leading to chafing.
Axillary hyperhidrosis may be malodorous, causing social embarrassment.
Hyperhidrosis exists in 2 forms:
1. Generalized hyperhidrosis may be secondary to numerous conditions including the following:
2. Localized hyperhidrosis ( in which it affects the palms, feet, face or armpits either individually or in a combination ).Unlike sweating on the remainder of the body, sweating on the palms and feet is controlled solely by the cerebral cortex and is responsive to emotional stimuli rather than to temperature stimuli. Both emotional and thermoregulatory stimuli control sweating in the axillae. Therefore, palmoplantar hyperhidrosis, unlike generalized hyperhidrosis, does not occur during sleep or sedation.
Hyperhidrosis is difficult to treat effectively.
With the newer treatment modalities now available, the patient has numerous options and is offered a better prognosis.
Patients should be educated regarding all of the treatment options, including their corresponding complications and costs.
Investigating a person of hyperhidrosis
Search for primary causes if generalized hyperhidrosis is noted.
Important laboratory studies may include the following:
How do I know this is hyperhidrosis and not nervousness / underconfidence?
While every one has increased sweating during stress, it is hyperhidrosis when sweat starts to drip.
Will it go away as I grow older?
Possible, but one cannot be sure. Ask your parents if they too suffered during their youth and if it got better.
Is there a local treatment?
Local solutions, antiperspirants, iontophoresis, botulinum toxin are temporary relief measures.
Is there a treatment where I can eat medicines to cure it ?
Unfortunately, as of now, there are NO medicines available for this. Tablets like sleeping pills, sedatives, anti anxiety medicines and anti-secretory medicines may initially make you feel better but soon you will realize that they are useless.
When is surgery required?
When your quality of life is getting affected by the problem and you are totally fed up.
What are the types of surgery? Which one is suitable for me?
ETS is the treatment of choice and gold standard with which all other methods are compared.
How much does the treatment cost?
About $3,000 in India, $10,000 in Taiwan, $20,000 in USA ( figures vary from centre to centre )
Is surgery a permanent cure? What are its side effects?
Yes it is a permanent cure with a success rate close to 98% as per most reported studies and data. Some patients can get compensatory sweating ( read below )
Is it done under general or local anesthesia? How long does one stay in the hospital?
I do it under general anesthesia and patient stays for 12- 24 hours after surgery ( depends on individuals )
What is compensatory sweating? Who gets it?
The sweat that is reduced, gets re-distributed to the rest of the body. Most patients have not been bothered by this complaint but international figures and data suggest upto 60% patients can have this. This is the main side effect of the surgery and does not have any known remedies. DO NOT consider surgery if you are not prepared for this side effect.
Is the surgery reversible in case I do not like it?
ETS- clipping is theoretically reversible, but no one can assure it. So consider ETS after talking to previous patients and understanding the effects.
Therapy can be challenging for both the patient and the physician. Both topical and systemic medications have been used. Other treatment options include iontophoresis and botulinum toxin injections. ( WARNING: Following treatment should not be tried by a patient without recommendation of a specialist doctor )
1. Topical agents include topical anticholinergics, boric acid, 2-5% tannic acid solutions, resorcinol, potassium permanganate, formaldehyde (which may cause sensitization, glutaraldehyde, and methenamine.
Drysol (20% aluminum chloride hexahydrate in absolute anhydrous ethyl alcohol is usually the most effective topical agent. Drysol should be applied nightly on dry skin with or without occlusion until a positive result is obtained, after which the intervals between applications may be lengthened. To minimize irritation, the remainder of the medication should be washed off when the patient awakes, and the area may be neutralized with the topical application of baking soda.
2. Systemic agents used to treat hyperhidrosis include anticholinergic medications. Anticholinergics such as propantheline bromide, glycopyrrolate, oxybutynin, and benztropine are effective because the preglandular neurotransmitter for sweat secretion is acetylcholine (although the sympathetic nervous system innervates the eccrine sweat glands). The use of anticholinergics may be unappealing because their adverse effect profile includes, blurry vision, dry mouth and eyes, difficulty with urination, and constipation. In addition, other systemic medications, such as sedatives and tranquilizers, indomethacin, and calcium channel blockers, may be beneficial in the treatment of palmoplantar hyperhidrosis.
3. Iontophoresis was introduced in 1952 and consists of passing a direct current across the skin. The mechanism of action remains under debate.
4. Botulinum toxin injections are effective because of their anticholinergic effects at the neuromuscular junction and in the postganglionic sympathetic cholinergic nerves in the sweat glands.
In palmar hyperhidrosis,
50 subepidermal injections of 2 mouse units per palm
(total 100 mouse units per palm) results in anhydrosis lasting 4-12 months (Shelley, 1998). Each injection produces an area of anhydrosis approximately 1.2 cm in diameter. The only
adverse effect is mild transient thumb weakness that resolves within 3 weeks.
Noted adverse effects include minor muscle weakness at the toxin-treated sites,
which usually resolves after 2-5 weeks. Injections of botulinum toxin must be repeated at varying intervals to maintain long-term results.
Results have been best in cases of isolated axillary hyperhidrosis.
Results have been best in cases of isolated axillary hyperhidrosis.
In addition to pharmacologic therapy, other treatments include surgical sympathectomy, surgical excision of the affected areas, and subcutaneous liposuction. Each modality has been used effectively.
1. Sympathectomy has been used as a permanent effective treatment since 1920. Usually, it is reserved for the final treatment option. Sympathectomy involves the surgical destruction of the ganglia responsible for hyperhidrosis. The sympathetic nervous system controls only sweating and does not affect touching or muscle function. Thus, clamping the sympathetic nervous system does not lead to numbness or paralysis.
The second (T2) thoracic ganglia controls facial hyperhidrosis,.third (T3) thoracic ganglia is responsible for palmar hyperhidrosis, the fourth (T4) thoracic ganglia controls axillary hyperhidrosis.
Two surgical approaches are available:
The techniques of open surgical access to the upper thoracic sympathetic chain are multiple, but they all share the drawbacks of being major surgical procedures with considerable risk of complications and sizable scars. There has therefore been an understandable reluctance of both doctors and patients to adopt this method in the treatment of hyperhidrosis. Thoracic surgeons utilize the following surgical approaches:
Transthoracic (large open chest incision)
Transaxillary (through the armpits with a open incision)
Anterior transthoracic (through the front of the chest with a large incision).
Recently, the endoscopic approach
has become favored because of its improvements in terms of complications,
surgical scars, and surgical times. Thoracoscopy was first performed in 1910,
and the first report describing this method of performing sympathectomy appeared in 1942. In
Chain picked below T2 Divided with cautery Nerve of Kuntz Skin cut glued together
CLICK HERE to see a video clip of the above procedure.
In 1954, an Austrian surgeon pioneered the technique of Endoscopic Upper Thoracic Sympathectomy (ETS). Subsequent improvements in the science of optics and instrumentation led to the refinement of the ETS procedure by creating smaller instruments that can visualize and clip the sympathetic nerves.
The sympathectomy procedure has evolved over the past 60 years. What began as an open chest operation is now being performed with small scopes and cameras. The sympathetic nerve trunks are no longer removed or destroyed, but instead are now clamped. The new procedure is called an Endoscopic Transthoracic Sympathetic Blockade (ETB) with Metallic Clips. It is also referred to as an Endoscopic Transthoracic Sympathectomy - Clip (ETS-C). The terms ETB and ETS-C are interchangeable and mean the same.
Complications are possible with this endoscopic treatment option; these include compensatory sweating (induction of sweating in previously unaffected areas of the body), gustatory sweating, pneumothorax, intercostal neuralgia, Horner syndrome (in case of T1 surgery), recurrence of hyperhidrosis (due to left behind nerve of Kuntz or aberrant nerves) , and the sequelae of general anesthetic use. Of 850 patients who underwent endoscopic transthoracic sympathectomy, 55% had compensatory sweating (mostly on the trunk), and 36% had gustatory sweating (Drott, 1995). In a similar study of 72 patients who underwent transthoracic endoscopic sympathectomy (T2 or T2 and T3) for palmar hyperhidrosis, the success rate was 93%; compensatory sweating occurred in most of the patients within 1 month after surgery, and gustatory sweating occurred in 17% (Lai, 1997).
For more on compensatory sweating, CLICK HERE
2. Surgical excision of the affected area (identified with iodine starch testing) removes the appropriate sweat glands, thereby eliminating sweating. This technique is particularly useful in axillary hyperhidrosis.
Subcutaneous liposuction is another means of removing the eccrine sweat glands responsible for axillary hyperhidrosis. Compared with classic surgical excision, this modality results in less disruption to the overlying skin, resulting in smaller surgical scars and a diminished area of hair loss.
On a lighter note: 46 patients underwent the procedure before their wedding and in 1 case patient's wife said that they were planning their 2nd honeymoon !!
1. Dr Chien-Chih Lin, from the Department of surgery, Taiwan, said the following in an article published in European Journal of Surgery
Thoracoscopic T2-sympathectomy or sympathicotomy (without removal of ganglia) is considered the best treatment for hyperhidrosis. However, the main disadvantage of this procedure is its irreversibility. As sympathetic nerve regeneration is impossible to control after sympathectomy, this usually leads to compensatory sweating over the trunk or back – a consequence some patients regret, even to the extent of preferring the original sweaty hands.
Denny-Brown and Brenner proved that without transecting the nerve trunk, nerve conduction could be interrupted by a compression force of more than 44 grams. The present endoscopic clips exert a force of approximately 150 grams. This force is obviously high enough to block the transmission of sympathetic impulses. Based on this principle, thoracoscopic T2-sympathetic blockade by endoscopic clipping was performed for hyperhidrotic patients.
Dr Garza from Texas,
A sympathetic blockade is a procedure where clamps are applied to specific nerve trunks. These nerve trunks carry the nerve signal from the brain to the face, hands, underarms or feet, which then causes excessive sweating. Thus, the sympathetic nerves in the chest are not the direct cause of hyperhidrosis, but transmit the nerve signals that begin the sweat response. In cases of sweating of the hands, underarms, scalp and face as well as facial blushing, the nerves that control these areas are located in the chest. The nerves spread out like a spider web to each location.
1. The first thoracic trunk and ganglion (T1) control the sweat response mostly in the face, then in the hands, and ,to a lesser extent, in the underarms. The first ganglia (also called the Stellate ganglia) also control the eyelid and pupil response. This ganglion should be spared.
2. The second trunk (T2) controls the sweat response in the hand and face and facial blushing. It is the preferred nerve to be clamped to control facial blushing and sweating. It also affects sweating of the hand.
3. The third thoracic trunk (T3) also affects hand sweating.
4. The fourth thoracic trunk (T4) affects hand and underarm sweating.
Effectiveness of Sympathectomy for Hand Sweat
The suggesated technique spares the 2nd sympathetic nerve trunk and clamps only the 3rd nerve trunk. This is effective in eliminating sweating of the hands and underarms in approximately 98% of patients who have this procedure and leads to a marked reduction in severe postoperative compensatory sweating which occurs during the standard T2 sympathectomy.
Effectiveness of Sympathectomy for Axillary (Armpit) Sweat
The latest recommendation for treating severe sweating of the underarms is to divide the T4 nerve trunk. The effect is immediate cessation of underarm sweating in 80% of all patients.
The T4 sympathectomy is known for a marked reduction in severe compensatory sweating. The reason for this change in compensatory sweating is because clamping the 2nd nerve trunk also stops sweating in the face and head. The face and head alone are responsible for over 44% of all heat released from the body. Once the T2 nerve trunk is clamped or cut, that 44% of body heat loss has to be released elsewhere throughout the body and will create more sweating on the trunk, groin, buttocks and legs.
Effectiveness of Sympathectomy for Facial and Scalp Sweat
An ETS for facial and scalp hyperhidrosis is about 95% to 98% successful. The T2 nerve trunk is clamped and is effective in 98% of the time. The problem with a T2 or T3 sympathectomy is that it will often lead to the side effect of compensatory sweating.
Effectiveness of Sympathectomy for Facial Blush
An ETS is successful in treating facial blush in about 85% of all patients. It is recommended to divide across the T2 nerve trunk. In the remaining 15% of cases, the intense blushing returns. The theoretical reason for failure in these cases is because the T1 nerve trunk or ganglion may have more control over the facial blushing than the T2 nerve trunk. The T1 nerve trunk, however, should not be disturbed because it will lead to paralysis of the eyelid muscle and cause a droopy eyelid.
Effectiveness of Sympathectomy for Foot Sweat
Although approximately 60% of patients who undergo an ETS for hand sweating will benefit from the elimination or significant reduction of foot sweating, this procedure is not recommended to treat primary foot hyperhidrosis. Those who wake up after surgery with dry feet may be disappointed to discover that the foot sweating can recur within the first week to several years later. The only known surgical treatment of foot sweating is to perform a lumbar sympathectomy. However, this procedure may cause the side effect of urinary incontinence in women and retro-grade ejaculation in men
CLICK HERE to see a High Definition (HD) video clip of the ETS procedure. ( Video shows telescope entering, chain being picked up and divided, Kuntz fibers being diathermised and skin cut being closed by medical glue.)
Under general anesthesia, with a single lumen tracheal intubation, the patient is placed in semi-Fowler’s position with his arms abducted. Two ports are made. One port in the middle or posterior axillary line at the level of the nipple is made. The lung is then gently pushed down and a small endoscope (a long narrow tube with a light source and lens) is inserted into the left chest. The scope is inserted between the ribs and the chest space is seen on a video monitor (TV screen). Another port is made in the axilla for the insertion of the hooked diathermy probe or the endoscopic clip-applicator. The sympathetic trunk can be seen through the thoracoscope. Under video-assistance, the pleura is opened along the sympathetic trunk with the hooked diathermy probe. A segment of T3-sympathetic trunk is then meticulously mobilized from adjacent tissue without transecting the sympathetic trunk and its branches. The sympathetic chain is then either transected using the cautery (ETS) or clipped (ETS-C / ETB). Any Kuntz’s fibre found over the ribs on the side are similarly cauterized. These are accessory fibers that must be destroyed otherwise the procedure may not be successful. Trocars are removed while the lun g is inflated by the anesthesiologist. The ports are then closed with a single stitch/ medical glue..
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