Endoscopic Thoracic Sympathectomy

Abbas E. Abbas, MD

Chief of Thoracic Surgery,

Ochsner Clinic Medical Center

New Orleans, USA

aabbas@ochsner.org

Curso Cirugía Mínimamente Invasivo en Tórax12,13 y 14 de Noviembre del 2010

Indications

• Palmar and axillary hyperhydrosis

• Facial flushing• Upper extremity ischemia • Chronic regional pain syndrome

Hyperhydrosis

• Palmar, axillary, and plantar hyperhydrosis

• Excessive sweating of the palms of the hands, axillae, and soles of the feet

• Creates vocational, social, and medical impairments

Clinical Impact of Hyperhydrosis

• Vocational

Writing

Keyboard

Driving

Clothing

• Social

Hand shaking

Sales

Marketing

Hand holding

Clothing selection

Clothing changes

• Medical

Rashes

Fungal infections

Hyperhydrosis

• Primary (idiopathic)• Secondary

Hyperhydrosis• Primary

Over-stimulation of sympathetic nervous system

Most common form Unknown etiology Localized

• Palms• Axilla• Soles of feet• Scalp, face

Hyperhydrosis

• Secondary Hyperthyroidism, hypertension Diabetes / pheochromocytoma Menopause Obesity Drug use

• Anti-depressants• Anti-emetics

Treatment of Primary Hyperhydrosis

• Anti-perspirants• Iontophoresis• Botox • Systemic medications• Surgery

Axillary liposuction Excision of axillary tissue Sympathectomy

Treatment of Secondary Hyperhydrosis

• Treatment of the underlying condition

Medical Treatments

• Anti-persirants Aluminum chloride (Drysol) Glutaraldehyde, tannic acid,

astringent

Medical Treatments

• Iontophoresis / Drionics Second line treatment Palmar and plantar Electric current (15 – 30 mA) Immersion 20 minutes 2 – 3 times / week 70% effective in mild Hyperhydrosis Sweating returns after cessation of

treatment

Medical Treatments• Anticholinergics

Robinul 1 – 4 mg po TID• Dry mouth, urinary retention,

constipation, dizziness Oxybutynin (Ditropan) 10 – 20 mg po

daily• Dry mouth, dizziness

Rebound excessive sweating

Medical Treatments

• Alpha agonists Clonidine (Catapres) 0.1 to 0.3 daily

• Dry mouth, dizziness, sleepiness, fatigue

• Less effect over time• Rebound sweating

• Beta blockers Inderal 10 mg po tid or prn

Medical treatments

• Botox Chemical denervation of sweat glands 50 – 500 units injection

• Hands and axillae Repeat every 2 – 6 months Pain, hand weakness 1 – 2 weeks, dry

mouth, bladder paralysis, bowel inactivity Effective in 70 – 80% of axillae Effective in 25 – 40% of palms

Upper Extremity Ischemia

• Raynaud’s disease• Berger’s disease

Small vessel atherosclerosis

Chronic Regional Pain Syndrome

• CRPS, also known as Reflex Sympathetic Dystrophy

• Chronic severe pain due to prior injury

• Etiology unknown

Chronic Regional Pain Syndrome

• Findings Cool, mottled upper extremity Extremely sensitive to light touch Claw hand

• Some of the pain is mediated by Sympathetic Nerve Fibers

• Results 20 – 50 % reduction in narcotic usage

Surgical Sympathectomy• Cervical

Injury to neurovascular bundle• Trans-axillary

Poor exposure• Thoracotomy

Pain and expense• Posterior

Pain, exposure• VATS

Outpatient, low pain, good exposure

Sympathetic levels (web-like)• T1

Scalp and face Neck Hands 10%

• T2 Hands 90% Face 10%

• T3 Hands 90% Axilla 90%

• T4 Axilla 90% Chest 50%

Patient Selection

• Must fail conservative therapy Topical agents Iontophoresis Oral medication Botox

• Must rule out secondary cause Usually very general sweating

Patient education

• Compensatory sweating 4 to 40% Truncal and groin

• Treatment options• Sympathectomy procedure• Support group

VATS Sympathectomy technique

• Supine position, sitting up, arms out• Single lumen endotracheal tube• CO2 insufflation• Two 5 mm incisions • 5 mm endoscope• Long cautery, harmonic scalpel, or

clips

Surgical Technique

• 5 mm Incisions posterior to Pectoralis• 5 mm port, CO2 insufflation, 15 cm H20• 5 mm port, 5 mm Endoscope• 3 mm cautery

T2 Dan Miller, MD Emory T3, T4 Mayfield and Houck, Reisler

• Carry laterally 2 – 3 cm, Kuntz nerves.• Evacuate CO2 completely

Post-op

• Immediate extubation• PACU CXR

Small pneumothorax common• Instructions regarding chest pain

and shortness of breath• Home with Hydrocodone/APAP

Single Level T2 Sympathectomy

• 50 patients (41 female)• T2 and accessory nerves only • Single-lumen endotracheal tube • CO2 insufflation• Single bilateral access incisions (4 mm)• 3-mm, 30-degree thoracoscope,• Electrocautery nerve division, and no chest drainage.• Median operating time was 22 minutes (14 – 35)• 100% outpatient• Pain at 3 months 1%• Outcomes

98% no sweating (1 pt required reop for T3) 12% compensatory sweating

Miller, D et al. Ann Thorac Surg 2007;83:1850 –3

Sympathectomy Level And Compensatory Hyperhidrosis After Sympathectomy

• 282 with palmar hyperhidrosis 179 patients (64%): division at T2 level only 103 at levels T2, T3, and T4

• Operative time 19 min (14 – 30)• Hospital stay 0 – 1 days

1% inpatient – pain• Results

99% no sweating 0% Horner’s Syndrome 0% gustatory sweating Compensatory hyperhidrosis

• 23 pts in T2 group (13%) • 35 pts in T2 - T4 group (34%; P = .011)

Miller, D et al. J Thorac Cardiovasc Surg 2009;138:581-585

Temporary Thoracoscopic Sympathetic Block for Hyperhidrosis

• 25 patients concerned about CH were scheduled for VATS block first

• 2.5 cc marcaine 0.25% block at T2-T3 and accessory nerves

• 100% no sweating in target areas with duration 2 – 10 days

• 12% (3 pts) compensatory sweating (2 mild, 1 severe)• One patient declined further sympathectomy due to CH• At VATS sympathectomy

100% no sweating5% compensatory sweatingAll pts satisfied

Miller, D et al. Annals of Thoracic Surgery 2008,  85 (4), pp. 1211-1216

Summary• Hyperhydrosis, CRPS, ischemia• Medical treatment first

Aluminum chloride PO medications Botox Iontophoresis

• Surgery Axillary fat pad resection VATS Sympathectomy

With special thanks to:

• Dr. William Mayfield: WellStar Thoracic Surgery, Marietta, GA

• For his support with much of the material presented