Overview
Definition:
Thoracoscopic sympathectomy, specifically Endoscopic Thoracic Sympathectomy (ETS), is a minimally invasive surgical procedure that involves the interruption or destruction of sympathetic nerve fibers, typically the sympathetic chain, to treat conditions characterized by excessive sweating (hyperhidrosis)
This procedure is primarily indicated for severe, debilitating primary hyperhidrosis affecting the hands (palmar), face (facial), or armpits (axillary), which has failed to respond to conservative management.
Epidemiology:
Primary hyperhidrosis affects approximately 1-3% of the population globally, with palmar hyperhidrosis being the most common form (around 70% of cases)
Facial hyperhidrosis is less common, and axillary hyperhidrosis is also frequent
The condition typically begins in adolescence or early adulthood and can significantly impact social and professional life
ETS is a widely performed procedure for refractory cases.
Clinical Significance:
Untreated severe hyperhidrosis can lead to significant psychosocial distress, including anxiety, embarrassment, reduced self-esteem, and avoidance of social situations
It can also cause practical issues like difficulty holding instruments, writing, or using electronic devices
Thoracoscopic sympathectomy offers a definitive solution for many patients, significantly improving their quality of life when conservative measures fail
Understanding the procedure, indications, risks, and management of complications is crucial for surgical residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Excessive sweating predominantly affecting palms, soles, face, or axillae
Symptoms often start during adolescence
Sweating is often exacerbated by emotional stress, certain foods, or hot weather
Episodes of excessive sweating are typically bilateral and symmetrical
Patients may report skin maceration, fungal infections, and malodor in affected areas
Social and occupational impairment due to sweating
The condition typically improves with sleep.
Signs:
Visible sweat on affected areas, often profusely
Skin may appear clammy or macerated
In facial hyperhidrosis, visible facial sweating may occur
Axillary hyperhidrosis presents with drenching sweat in the armpits
No other underlying medical condition or medication is identified as the cause.
Diagnostic Criteria:
The diagnosis of primary hyperhidrosis is typically clinical, based on the presence of at least two of the following criteria for at least 6 months: bilateral and roughly symmetrical localization
sweating that impairs daily activities
at least one episode per week
onset before 25 years of age
positive family history
cessation of sweating during sleep.
Diagnostic Approach
History Taking:
Detailed history focusing on the location, severity, duration, and triggers of sweating
Quantify the impact on daily life, social interactions, and occupation
Inquire about previous treatments and their efficacy
Rule out secondary causes of hyperhidrosis (e.g., hyperthyroidism, pheochromocytoma, carcinoid syndrome, menopausal hot flashes, certain medications like SSRIs or anticholinesterases)
Assess for psychological comorbidities like anxiety or depression.
Physical Examination:
General examination to assess for signs of secondary hyperhidrosis
Detailed examination of the affected areas (palms, soles, axillae, face) to assess the extent and severity of sweating
Examine skin for maceration or signs of infection
Assess for neurological deficits
Palpate lymph nodes for lymphadenopathy.
Investigations:
Generally, investigations are not required to diagnose primary hyperhidrosis
However, if secondary hyperhidrosis is suspected, basic blood tests may include thyroid function tests (TSH, fT3, fT4), blood glucose, and urine analysis
If carcinoid syndrome is suspected, 5-HIAA levels in urine may be checked
If pheochromocytoma is a concern, serum or urinary metanephrines are indicated
Imaging like chest X-ray is not routinely required for primary palmar or axillary hyperhidrosis unless complications are suspected.
Differential Diagnosis:
Secondary hyperhidrosis due to endocrine disorders (hyperthyroidism, diabetes mellitus, hypoglycemia), infections (tuberculosis), malignancies (lymphoma, leukemia, pheochromocytoma, carcinoid tumor), neurological conditions (spinal cord injury, autonomic neuropathy), and pharmacologic side effects
Emotional sweating and gustatory sweating (e.g., with parotid surgery) should also be considered.
Management
Initial Management:
Conservative management for hyperhidrosis includes topical antiperspirants (aluminum chloride hexahydrate 10-20%), iontophoresis (especially for hands and feet), oral anticholinergic medications (e.g., glycopyrrolate, oxybutynin), and botulinum toxin injections
Psychological counseling and stress management techniques may also be beneficial.
Medical Management:
Topical antiperspirants: Applied nightly to dry skin
Iontophoresis: Daily sessions of 15-30 minutes using tap water and a mild electrical current
Oral anticholinergics: Glycopyrrolate 1-2 mg PO TID or Oxybutynin 2.5-5 mg PO BID, doses titrated for efficacy and side effects (dry mouth, constipation, blurred vision, urinary retention)
Botulinum toxin injections: Effective for axillary hyperhidrosis, requires repeat injections every 4-12 months
Less commonly used for palmar hyperhidrosis due to pain and potential motor weakness.
Surgical Management:
Endoscopic Thoracic Sympathectomy (ETS): Indicated for severe hyperhidrosis unresponsive to conservative measures
The procedure involves interrupting the sympathetic chain at specific levels (typically T2-T4 for palmar hyperhidrosis, T2-T3 for facial, and T4-T5 for axillary)
Techniques include clipping, cautery, or resection of the sympathetic chain
The approach is video-assisted, requiring small incisions in the axilla or chest wall
Bilateral procedures are usually staged or performed simultaneously depending on surgeon preference and patient risk.
Supportive Care:
Postoperative pain management is crucial
Patients require monitoring for potential complications such as pneumothorax, bleeding, or nerve injury
Education on managing compensatory sweating is essential
Skin care advice is important to prevent maceration and infection in areas that may develop increased sweating post-surgery.
Complications
Early Complications:
Pneumothorax: Can occur during trocar insertion or dissection
Hemothorax: Due to vascular injury
Air embolism: Rare but potentially catastrophic
Persistent pain: Chest wall pain or nerve-related pain
Horner's syndrome: Ptosis, miosis, anhidrosis of the face (typically associated with high sympathectomy, T1 or above).
Late Complications:
Compensatory hyperhidrosis (CH): The most common and significant complication, affecting approximately 30-70% of patients, where sweating increases in other body areas (trunk, legs, back)
Gustatory sweating: Sweating of the face and neck during mastication
Recurrence of original hyperhidrosis: Rare but can occur if sympathectomy is incomplete
Chronic pain syndromes
Dry eye syndrome (especially with higher sympathectomies).
Prevention Strategies:
Meticulous surgical technique to avoid injury to intercostal vessels and pleura
Precise identification and targeting of sympathetic chain segments to minimize risk of Horner's syndrome and unintended denervation
Careful patient selection to ensure adequate trial of conservative management
Preoperative counseling regarding the high incidence and potential severity of compensatory hyperhidrosis
Staging bilateral procedures may reduce cardiovascular and respiratory risks.
Prognosis
Factors Affecting Prognosis:
Success in alleviating primary hyperhidrosis is generally high (85-95%)
However, the development and severity of compensatory hyperhidrosis (CH) significantly impact long-term patient satisfaction
Younger age, more severe primary hyperhidrosis, and bilateral sympathectomy may be associated with a higher risk of severe CH
Patient expectations and psychological well-being are also critical factors.
Outcomes:
For primary hyperhidrosis, ETS provides significant and often complete relief of sweating in the targeted areas for the majority of patients
Quality of life improvements are substantial for those who do not develop severe compensatory sweating
Compensatory hyperhidrosis can range from mild and manageable to severe and debilitating, sometimes requiring further management strategies
Recurrence of original hyperhidrosis is uncommon.
Follow Up:
Postoperative follow-up is essential to monitor for early complications and assess the effectiveness of the sympathectomy
Long-term follow-up is required to monitor for the development or progression of compensatory hyperhidrosis and to assess patient satisfaction with the overall outcome
Regular visits at 1 week, 1 month, 6 months, and annually thereafter are typical, with adjustments based on individual patient needs.
Key Points
Exam Focus:
Understand indications for ETS (severe, refractory primary hyperhidrosis)
Know the sympathetic chain levels targeted for palmar (T2-T4), facial (T2-T3), and axillary (T4-T5) hyperhidrosis
Recognize Horner's syndrome as a potential complication of higher sympathectomies
Be aware of compensatory hyperhidrosis (CH) as the most common and impactful complication, affecting 30-70% of patients
Differentiate primary from secondary hyperhidrosis.
Clinical Pearls:
Always start with conservative management (topical antiperspirants, iontophoresis, botox)
Thoroughly counsel patients about the significant risk of compensatory sweating before considering surgery
For palmar hyperhidrosis, targeting T3 and T4 is often sufficient to minimize risk of facial sweating and Horner's syndrome
Consider staging bilateral sympathectomies in high-risk patients
Reassurance and psychological support are vital for patients experiencing significant CH.
Common Mistakes:
Performing ETS for mild or secondary hyperhidrosis
Inadequate patient selection and counseling regarding risks, especially CH
Incomplete sympathetic denervation leading to recurrence of hyperhidrosis
Overtreating by resecting too much of the sympathetic chain, increasing risk of Horner's syndrome and CH
Failing to consider medical management options adequately before resorting to surgery.