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Differens options in thoracoscopic sympathectomy

Differens options in thoracoscopic sympathectomy. Hans Pilegaard, Ass. Prof, MD Department of Cardiothoracic Surgery Aarhus University Hospital, Skejby Denmark 13th Turkish Thoracic Society Congress Istanbul Turkey. Hyperhidrosis. National questionnaire 150.000 households

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Differens options in thoracoscopic sympathectomy

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  1. Differens options in thoracoscopicsympathectomy Hans Pilegaard, Ass. Prof, MD Department of Cardiothoracic Surgery Aarhus University Hospital, Skejby Denmark 13th Turkish Thoracic Society Congress Istanbul Turkey

  2. Hyperhidrosis • National questionnaire 150.000 households • USprevalence 2.8% • 7.8 millions individuals • 4 millions axillar • work emotional psychological social Strutton et al. J Am Acad Dermatol 2004; 51:241-248

  3. Hyperhidrosis • Blushing • Facial • Palmar • Axillary • Foot • Raynaud syndrome • Cardiac arrhytmia? • Angina pectoris? Thoracoscopic treatment

  4. Topical Aluminium chloride (AlCl3-6H2O) Anticholinergic agents Astringent agents (Glutaraldehyde, formalin) Iontophoresis Botulinum toxin Excision of glands in the axillary region Liposuction Laser treatment

  5. Opensympathectomy ThoracotomyKotzareff 1920 Kotzareff A. Rev Med Suisse Romande 1920; 40:111-113 Supraclavicular approach Telford 1935 Telford E. Br J Surg 1935; 23:448-450 Anterior approach Polumbo 1956 Polumbo LT. ArchSurg 1956;72:659-66 TransaxillaryGoets & Marr 1944 Goets R, Marr J. ClinicalProceedings 1944; 3:102-114 PosteriorAdson 1929 Cloward 1969 Cloward. J Neurosurgery 1969; 30:545-551 AxillarextrapleuralRoos 1971 Roos D. Ann Surg 1971; 173:429-442

  6. Thoracoscopicsympathectomy Thoracoscopy Hughes 1942 Hughes J. Proc Royal Soc Med 1942; 35:585-586 ThoracoscopyGoets & Marr 1944 Goets R, Marr J. ClinicalProceedings 1944; 3:102-114 ThoracoscopyKux 1946-54 Kux E. Georg ThiemeVerlag, Stuttgart 1954 VATS 1980´s -

  7. Thoracoscopicsympathectomy Easy Fast (minuttes) Good visualization Small incisions Outpatient Awake Local anaestesia Elia et al. Awake one stage bilateral thoracoscopic sympathectomy for palmar hyperhidrosis: A safe outpatient procedure. 2nd EACTS/ESTS joint meeting, Leipzig, Germany 2004

  8. Definitions • Sympathotomy • Transection • Sympathectomy • Resection • Ablation

  9. Thoracoscopy • Needle, 5mm, 10mm • Uniportal • 2 ports • 3 ports can be necessary

  10. Methods • Electrocoagulation • Harmonic scalpel • Laser • Clipping • Reversal

  11. Electric vsharmonicscalpel • Non randomized prospective • N=1515 patients • 24 hours, 7 days and 30 days • Responserate: 90%/68%/27% • No difference either by method or level de Campos JR et al. ICVTS: in pressJR

  12. Clipping • N=727 patients – responsrate 92% • T2: 399, T2+3: 55, T3+4: 273 • 34 patients have had clip removed • T2: 21, T2+3: 7, T3+4: 6 • 15 patients. decrease in compensatory sweating Sugimura H et al. J Thor Cardiovasc Surg 2009;137(6): 1370-8

  13. Method Supine Single lumen tube Two ports Harmonicscalpel ReverseTrendelenburg

  14. Sympathectomylevel BlushingTh 2 PalmarTh 2-3 AxillaryTh 2-3-4

  15. Sympathicotomy - left

  16. Facialblushing and hyperhidrosis T1-T2-T3 Drott et al. Br j Dermatol 1998;138:639-43. T2 Kim et al. Eur J Cardiothor Surg 2004;26:396-400 Doolabh et al. Ann Thor Surg 2004;77:410-4 Dewey et al. Ann Thor Surg 2006;81:1227-33 Chou et al. Surg Endoscpo 2006;20:1749-53 Licht et al. Ann Thor Surg 2006;81:1863-6 Weksler et al. Thorac Surg Clin 2008;18:183-191 T2-T3 Drott et al. J Cosmet Dermatol 2000;1:115-9 Licht et al. Ann Thor Surg 2006;81:1863-6

  17. Facialblushing and hyperhidrosis • Follow-up questionaire – 2 centers • N=189 • Responsrate 96% • Outcome similar • Compensatory sweating • T2 83% - T2-3 95% p=0.02 Licht et al. Ann Thor Surg 2006;81:1863-6

  18. Facialblushing • RCT • T2 vs T2-T3 • Study size n=200 • N= 55 • No difference

  19. Palmarhyperhidrosis +200 papers Most recommend T2-T3 Chiou TS & Chen SC. Br J Surg 1999; 86:45-47 Reisfeld R et al. Surg Laparosc Endosc Percutan Tech 2002; 12:255-267 Kao MC. Ann Thorac Surg 2001; 72:667-668 Andrews & Rennie JA. Br J Surg 1997; 84:1702-1704 Lin CC. Surg Endosc 1990; 4:224-226 T2 Dumont P et al. Ann Thorac Surg 2005; 78:1801-1807 Zacherl J et al. Ann Thorac Surg 1999; 68:1177-1181 Gossot D et al. Ann Thorac Surg 2003; 75:1075-1079 T2-T4 T2-T5 Yilmaz EN et al. Eur J Cardiothorac Surg 1996; 10:168-172 Lardinois D & Ris HB. Eur J Cardiothorac Surg 2002; 21:67-70 Nicholson ML et al. Ann R Coll Surg Engl 1994; 76:311-314

  20. T2 vs T3Palmarhyperhidrosis • N= 60 patients • Succesrate: 59/60 • Compensatory hyperhidrosis • No differens in number, but in severity • T2/T3: 13/4 p= 0.007 Yazbek G et al: Clinics 2009;64(8):743-9Yazbe

  21. T3 vs T2-T4Palmarhyperhidrosis • N= 232 patients Xu Li et al. Ann Thor Surg 2008;85:1747-52

  22. Axillaryhyperhidrosis T2-T4 Zacherl J al. Ann Thorac Surg 1999; 68:1177-1181 Hsu CP et al. Arch Surg 2001; 136:1115-1117 Dumont P et al. Ann Thorac Surg 2005; 78:1801-1807 Rex LO et al. Eur J Surg Suppl 1998;23-26 Drott C & Claes G. Cardiovasc Surg 1996; 4:788-790 Ahn SS et al. Ann Vasc Surg 2000; 14:415-420 T2-T3 Fox AD et al. Eur J Vasc Endovasc Surg 1999; 17:343-346 Andrews BT & Rennie JA. Br J Surg 1997; 84:1702-1704 Kao MC et al. Ann Acad Med Singapore 1996; 25:673-678 T2 Chiou TS & Chen SC. Br J Surg 1999; 86:45-47

  23. T4 vs T3-4Axillaryhyperhidrosis • N= 64 patients • RCT Compensatory sweating 6 mdr 12 mdr Munia MAS et al. Clinics 2008;63(6);771-4

  24. Compensatorysweating • N=158 patients • Responsrate 89% • T2 facial blushing and hyperhidrosis • T2-3 palmar hyperhidrosis • T2-4 axillary hyperhidrosis P=0.04 Licht et al. Ann Thor Surg 2004;78:427-31

  25. Gustatorysweating • N=238 patients • Responsrate 96% • Gustatory sweating 32% P=0.04 Licht et al. Ann Thor Surg 2006;81:1043-7

  26. Information to the patient • Succes rate • Sideeffects • Compensatory sweating • Gustatoric sweating • Horner’s syndrome • Heart rate • Definitiv operation • Telarenta T. Eur J Surg Suppl 1998;580:17-8

  27. Succesrate • Facial blushing and hyperhidrosis 90% • Palmar hyperhidrosis 100% • Axillary hyperhidrosis 80%

  28. Sideeffects • Compensatory sweating 90% • Gustatoric sweating 35% • Horner’s syndrome > 1% • Heart rate at rest 10% • Dry hands • Return to basic not a possibility

  29. Side effect - Harlequin • 1997-2007 • N=669 • 48 reoperation 80% compensatory sweating 38% worsening Licht et al. Ann thor Surg 2010;89:1087-90 Eur J Cardiothor Surg 2010;37:959

  30. Conclusion T2 for facialblushing and hyperhidrosis T3 for palmarhyperhidrosis T4 for axillaryhyperhidrosis

  31. Conclusion Most patients aresatisfiedwith the operation 90% of the patients willgetcompensatorysweating Signifikant compensatorysweating is more frequentafter T2-4 sympathectomi for axillaryhyperhidrosis

  32. Conclusion Good information before the operation is mandatory

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