Endoscopic Thoracic Sympathectomy for Palmar Hyperhidrosis: a Retrospective Review of 826 cases
Tu Yuan-rong,, Li Xu, Lin min,Lai Fan-cai, Chen Jian-feng.
(Department of Thoracic Surgery,The First Affiliated Hospital of Fujian Medical University,Fuzhou,350005. )
Primary palmar hyperhidrosis is distressing and often socially disabling conditions. Endothoracoscopic sympathectomy (ETS) has ready been proved to a simple, safe, reliable, and cost-effective therapy in patients with primary hyperhidrosis, offering long-term relief of symptom. Large published series have shown success rates of 95-100% following ETS with improved quality of life and treatment satisfaction of 93-95%. There were several thoracoscopic methods have been described with different access sites and different operative approaches. Nonetheless, the benign nature of the disease mandates that any medical intervention should be extraordinarily safe, minimally invasive, and produce fewer side effects. Thus, a retrospective review of 826 patients who were afflicted with bilateral thoracoscopic sympathectomy was conducted.
Patients From Jan 2003 to Mar 2009, 826 patients with palmar hyperhidrosis were treated by bilateral endoscopic thoracic sympathectomy at our institution for isolated palmar hyperhidrosis or combination of palmar and other body part hyperhidrosis. 418 patients were female and 408 cases were male (age range 10-53 years, mean 21.3 years). Inclusion criteria: Moderate or severe palmar hyperhidrosis without contraindication for an anesthetic procedure. Exclusion criteria: (1) Pleural or pulmonary disorder indicated by chest X-ray or CT scan. (2) Secondary hyperhidrosis including hyperthyroidism, acute and chronic infections and malignancy. (3) Past history of thoracotomy. Informed consent was obtained in writing at least 1 day before surgery through the surgeon after careful explanation of the goal and side-effect of the operation.
Anesthesia All patients received premedication with intra muscular atropine and barbiturate. Anesthesia was induced with intravenous fentanyl, thiamylal and cisatracurium.One of following three methods was performed: (1) Double lumen endotracheal tube (235 cases); (2) Single lumen endotracheal tube (526 cases); (3) Laryngeal madk airway (65cases).
Surgical Procedure (1) One port method (102 cases): The patient was placed on the operating table in a semisitting position with arms in abduction. After disconnection of airway circuit, the HOPKINS® straight forward telescope ( 10mm, with angled eyepiece, Karl Storz GmbH & Co. KG, Tuttlingen, Germany ) was introduced through a 11mm port in the right third intercostal space behind the border of the pectoralis major muscle. The dissecting electrode (5mm) was inserted through the working channel in the telescope.
(2) Two port method (724 cases): The thoracoscope (5mm, 00, Karl Storz GmbH & Co. KG, Tuttlingen, Germany) was introduced through a 5.5mm port in the fifth intercostal space behind the border of the pectoralis major muscle. A second 5 mm port was introduced in the third intercostals space on the anterior axillary line.
The sympathetic chain was identified at the level of the crossing of the corresponding costal heads. The parietal pleura were opened, and the sympathetic chain at this level was transected by diathermy (213 cases of T2-T4 transection, 163 cases of T3-T4 transection, 410 cases of T3 transection, and 40 cases of T4 transection in our series). The incision was extended laterally for approximately 3 cm on the costal head to include any accessory nerve fibers (the nerve of Kuntz ). All procedures were completed by insertion of a 16F chest tube through trocar, and the lung was reinflated under visual control. The chest tube was aspirated while the anesthesiologist ventilated the patient manually, exerting continuous positive pressure for a few seconds, to prevent pneumothorax before the drain was subsequently removed. Confirmation of the sympathetic blockade was documented by an immediate rise in the temperature of upper limb through a thermoprobe taped on the patients’ finger. A postoperative chest X-ray was taken in search of lung inflation and to rule out the presence of residual pneumothorax.
Results All operations were successfully performed without morbidity and mortality. No conversion to open technique was necessary. All patients exhibited dry hand immediate after procedure with a significant finger temperature rise (2.8℃±0.9℃). The median duration of the surgical procedure was 10 minutes. The time was calculated from the time of skin incision to the application of the dressing over the wound. This excluded anesthesia induction and reversal time. Although intraoperative bleeding was observed in 2 patients, neither of them required hemostasis by open surgery. Most patients were discharged on the first postoperative day (mean hospital stay, 1.2 days). Two recurrent cases were observed at 8 months and 12 months after operation, one case was cured by redo procedure.
586 cases who underwent the procedures before Dec, 2007 were followed-up for the severity of the compensatory sweating. Compensatory sweating occurred in 109 (19%) of the 586 respondents, included: mild 12.2% (72/586); moderate 5.6% (33/586) and severe 0.7% (4/586). The satisfaction rate is 99%. The rate of compensatory sweating in T2 involved group (T2-T4 transection) was 28% (59/213) which was significantly higher than that in T2 free group (T3 or T4 or T3-T4 transection), the rate of compensatory sweating in latter group was 13.4% (50/373).
Comment
(1) ETS has been proved to be a simple, safe, reliable therapy in patients with primary hyperhidrosis, offering long-term relief of symptom.
(2) The surgeron could choose operative approach freely between the one port method and two port method.
(3) There are three methods for the airway management during the administration of anesthesia: double lumen endotracheal tube; single lumen endotracheal tube; and laryngeal madk airway. The anesthesiologist may select the most skillful one.
(4) The rate of compensatory sweating was significantly lower in T2 free group. (5)Informed consent before surgery is important; the warning of severe compensatory sweating should be included in the informed consent.
编辑: xiaoyan 作者:丁香园通讯员
以下网友留言只代表网友个人观点，不代表网站观点
