Single-port one-stage bilateral thoracoscopic sympathicotomy for severe hyperhidrosis: prospective analysis of a standardized approach

Primary hyperhidrosis (PHH) is characterized by excessive sweat secretion beyond the need for physiological thermoregulation without an underlying systemic condition. PHH tends to begin around the mid second to early third decade of life, affects men and woman equally and has a focal and often symmetric character [1]. It typically affects hands, feet and axillae, although combined palmar-axillary and craniofacial forms are relatively common as well.

Severe palmar and/or axillary focal PHH leads to feelings of shame and low self-esteem resulting in withdrawal from social activities, negatively affecting relational and professional development [2–4]. Although PHH is considered a benign disorder, it may have a deleterious impact on health related quality of life (HR-QoL). The reality that the latter has been underestimated until very recently is supported by the increasing reported prevalence in the literature, growing from 0.6% in 1977 to a recent 4.6% of the general population [1, 5, 6]. This observation substantiates that we might be looking at the tip of the iceberg called PHH. Non-surgical treatment modalities, like topical solutions, iontophoresis and botulinum toxin injections have proven to be temporarily successful in the treatment of PHH. However, non-surgical treatment modalities strain health care resources because of their temporary relief and demand a high level of patient compliance due to the need for repetitive administration. And while acceptable results have been achieved with local surgery that aims at the eccrine-gland level [7], these strategies are quite invasive and by nature only able to relieve axillary PHH.

Minimal invasive endoscopic thoracic sympathectomy (ETS) has become a well-established treatment modality and first-line treatment in palmar PHH. Large series have shown success rates of 71-100% following conventional ETS for all forms of PHH with improved quality of life and treatment satisfaction of 93-95% [8, 9]. Recent experience is obtained with even less-invasive surgery and single-port access techniques. Since results, methods, nomenclature and used instruments vary widely, we sought to study the feasibility of our standardized, one-stage bilateral, single-port sympathicotomy.

Various HR-QoL instruments have been described for impact measurement and intervention-effect quantification in PHH, including the Short Form 36 (SF-36), and a proposed disease specific questionnaire [9]. The sensitivity of a general HR-QoL instrument like the SF-36 is however limited by good general health status of this young, otherwise healthy population. Since hyperhidrosis specific QoL questionnaires often lack repeated validation and are not frequently used in the context of surgical intervention thus hindering comparison of results, we opted for the Skindex-29, a well-validated psychometric dermatologic questionnaire.

In the present study, in 67.0% of patients the overall Skindex-29 rating showed a severe impact on their quality of life. Interestingly, severe hyperhidrosis has a different impact on the three different HR-QoL domains measured. The severe impact on the emotions- and functioning-domains in well over three quarters of patients (79.4% respectively 84.5%) demonstrates the great emotional stress and seriously impaired social and professional functioning induced by severe PHH. In the symptoms-domain however, only 3.1% of patients rated a severe impact. This can be explained by the fact that hyperhidrosis produces little physical symptoms included in Skindex-29 like itching, bleeding and pain, and because of the fact that patients try to hide PHH reducing the impact of symptoms on HR-QoL. This strengthens the notion that PHH is a highly underestimated medical and social problem. In fact, several studies have shown the impact of hyperhidrosis on quality of life to be highly comparable to severe psoriasis, multiple sclerosis, vitiligo, rheumatoid arthritis and even end-stage renal failure [7, 15–17].

The HDSS proofs a valuable asset for patient selection and quantification of the perceived severity of PHH both pre- and postoperatively. Although not specifically designed for CHH impact detection, the post-operative HDSS seems to capture the true social impact of the sympathicotomy. Since CHH, when present, will influence the postoperative HDSS score, it provides a very easy to obtain, yet comprehensive outcome assessment.

This study reports the data of the further development of the previously described single-port operative technique [14] with the patient now positioned in beach chair position. Although not yet standard practice in most research groups we propose it should be since this position avoids possible complications associated with repositioning intubated and anaesthetized patients. Moreover it provides an easy access for one-stage bilateral sympathicotomy and reduces procedure time.

Despite proposed uniform terminology and nomenclature in describing sympathetic chain surgery, exact definitions regarding surgical access and level and type of sympathetic transection still vary greatly [18–22], while also different approaches for the different levels of intervention have been described [20]. Nomenclature of interventions like clipping, true sympathectomy (resection or ablation of a portion of the sympathetic chain including the ganglia) and sympathicotomy on different levels are variably used, leading to confusing results and hindering interpretation and comparison of results reported by different authors. In this study, we used the set of common definitions and standardized nomenclature as recently proposed by the Society of Thoracic Surgeons through Cerfolio et al. [23]. We wholeheartedly support these uniform terms, and their international future use. We believe they should be used by all groups who are working in the field of 'surgical treatment of hyperhidrosis’.

It is known that a single-port thoracoscopic approach causes less postoperative pain and a shorter operation and recovery time [18]. Better functional and cosmetic results of a truly minimally invasive single-port access compared with more conventional, but still frequently used bi- or tri-portal approaches render these multi-port strategies obsolete. In our study 45 patients (45%) were treated on outpatient basis. This percentage does not reflect medical implications since all patients were offered the possibility to stay the night following the procedure. This was done to reduce travelling risks because of the large referral area and to increase patient comfort. Three patients had to stay overnight for medical reasons (pleural drainage).

In recent literature high satisfaction rates (96.6% vs. 89.6%) combined with a significant lower incidence of severe CHH (3% vs. 10%) are obtained by performing only a R3 sympathicotomy for the treatment of PHH, and a R3-R5 sympathicotomy for combined palmar and axillary PHH [19]. According to this evidence, we performed a R3 sympathicotomy for isolated palmar PHH and a R3-R5 sympathicotomy for axillary or combined palmar/axillary PHH. By cauterizing the sympathetic chain at the top of R3, or top of R3-R5 while leaving the R2 level and all sympathetic ganglia intact, we performed a true sympathicotomy in this study. Very high rates of satisfaction (99%) and success (97% of patients had an 80% reduction in sweat production) were observed. Twenty-seven percent of patients reported CHH with an acceptable incidence of mild CHH (21%) and moderate CHH (6%) CHH. Severe CHH did not occur.

Opposite effects of sympathicolysis level on CHH have also been reported, with a low incidence of CHH after isolated R2 sympathectomy (13%) compared to R2-R4 sympathectomy (34%) [20]. However, patients who had division of the sympathetic chain at multiple levels, showed a significantly higher incidence of CHH. The high success-rates obtained in our study, with a relative low incidence of CHH, strengthens the theory that including the R2 level is not required for adequate PHH relief in any form of isolated palmar or combined palmar/axillary PHH, and is thus better avoided since it heightens the risk for Horner’s Syndrome [21]. It’s also known that a more extensive sympathetic denervation is correlated to a significant higher disturbance in bronchomotor tone and cardiac function, albeit on a sub-clinical level [24]. Perhaps the overlapping conclusion should be that less is more, meaning that lower CHH levels can be achieved by less damage to the sympathetic chain with a more selective sympathicolysis. While in axillary hyperhidrosis a R3-R5 sympathicotomy is adequate, we feel that an isolated R3 sympathicotomy suffices in the treatment of palmar hyperhidrosis, possibly offering the best compromise between success in treating PHH and the risk of CHH, by averting intervention at multiple levels.

Careful patient-selection using uniform, evidence based diagnostic criteria including disease-severity, a standardized operative procedure, unambiguous anatomical nomenclature, and adequate outcome assessment are key issues. Performing a highly selective sympathicotomy at well-defined levels using a single-port one-stage bilateral trans-axillary thoracoscopic approach, we combined a safe and minimally invasive surgical technique with excellent and reproducible immediate results in the treatment of primary palmar and/or axillary hyperhidrosis, rendering the practice of multi-port interventions in these patients superfluous. The HDSS was found an excellent measure with regard to patient selection, satisfaction and improvement in quality of life. Regardless of the excellent short-term results achieved, long-term follow-up studies including repeated HDSS and Skindex-29 questionnaires are needed to determine the life-long effects of thoracic sympathicotomy and its impact on everyday life for patients suffering from invalidating PHH.