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PubMed2004

Local neural block at the wrist for treatment of palmar hyperhidrosis with botulinum toxin: technical improvements.

BACKGROUND: Wrist blockage of median and ulnar nerves before treatment of palmar hyperhidrosis with botulinum toxin (BTX-A) reduces discomfort and improves accuracy of BTX-A injections, but can be associated with mechanical/chemical injury. OBJECTIVES: We sought to compare locoregional anesthesia of median and ulnar nerves using conventional 25-G x 0.50 x 13 mm gauge needle with short 30-G x 0.40 x 6 mm gauge needle. METHODS: In all, 37 patients with idiopathic, recalcitrant palmar hyperhidrosis were treated with BTX-A after median and ulnar nerve blockage. In 18 patients, a conventional needle was used to achieve nerve blockage and in 19 the short needle was used. The 2 groups of patients were compared for analgesic effects and lag phase. RESULTS: No differences were found between groups for lag phase (P=.26) and discomfort of subsequent BTX-A treatment (P=1.0). CONCLUSION: The use of a short-gauge needle to block median and ulnar nerves is a suitable method to anesthetize the palm before treatment with BTX-A.

Adult↗

PubMed2004

Sweat gland morphology and periglandular innervation in essential palmar hyperhidrosis before and after treatment with intradermal botulinum toxin.

BACKGROUND: Intradermal botulinum toxin (Btx) produces long-lasting relief of focal hyperhidrosis, but its mechanism of action is poorly understood. OBJECTIVE: To study the effect of Btx A on the size and innervation of sweat glands in patients with palmar hyperhidrosis. METHODS: Palmar skin biopsy was performed in 26 hyperhidrotic patients before scheduled Btx treatment and in 11 controls. Twelve of the patients also underwent biopsy 1 to 6 months after the Btx injections. Sweat gland morphology was investigated by light microscopy; the cross-sectional area of the secretory tubule and its lumen was measured by image analysis. Immunofluorescence (IF) with antibodies to the neural markers protein gene product 9.5 (PGP 9.5) and growth-associated protein 43 (GAP 43), and to vasoactive intestinal peptide (VIP) and calcitonin gene-related peptide (CGRP), was used to analyze the periglandular innervation. RESULTS: The gross morphology of the sweat glands was similar in patients and controls, with no significant differences in tubular and luminal areas between the groups. After Btx treatment, the tubular dimensions remained unchanged, but the lumen tended to be smaller ( P = .07). Around the glands, increased GAP 43 staining indicating sprouting was seen within 3 months after Btx treatment ( P = .016); whereas the PGP 9.5 staining was decreased in most specimens ( P = .09) indicating lack of functional nerve growth. No change in VIP or CGRP immunoreactivity was observed. CONCLUSIONS: The sweat glands appear structurally normal in hyperhidrotic patients before Btx therapy, whereas after therapy the luminal area of the gland is frequently diminished. The IF data GAP 43/PGP 9.5 suggest that Btx therapy induces long-standing functional denervation of the sweat glands, which might explain its anti-transpiratory efficacy.

Adolescent↗

PubMed2005

Palmar hyperhidrosis--which is the best level of denervation using video-assisted thoracoscopic sympathectomy: T2 or T3 ganglion?

PURPOSE: This study compares early results of video-assisted thoracoscopic sympathectomy (VTS) at the thoracic T2 versus T3 ganglion denervation levels for the treatment of palmar hyperhidrosis (PH). METHODS: Sixty patients with PH were prospectively randomized for VTS at the thoracic T2 or T3 ganglion denervation levels. The patients underwent postoperative evaluation on three occasions: before surgery, and 1 and 6 months after the operation. Endpoints included the absence of PH, the presence, location, and severity of compensatory hyperhidrosis (CH), and a quality-of-life assessment. RESULTS: Fifty-nine of 60 patients reported complete resolution of PH after surgery. One failure occurred in the T3 group. CH was observed in 26 patients (86.66%) in the T2 group and in 27 patients (90%) in the T3 group at 1 month. At 6 months, 30 of 30 patients in the T2 group and 29 of 30 in the T3 group experienced CH, although in the T3 group, CH was less severe at both 1 and 6 months (P < .05). Quality of life was very poor in both groups before surgery. One month after operation, quality of life was improved similarly in both groups. This improvement was maintained at 6 months in both groups. CONCLUSION: PH is well treated by VTS at either the T2 or T3 levels. Denervation at the T3 level appears associated with less severe CH in the early postoperative period. Quality of life improved significantly in both groups.

Adult↗

PubMed2006

Laser Doppler scanning study of palmar skin perfusion for patients with hyperhidrosis before and after thoracic sympathectomy.

BACKGROUND: Palmar hyperhidrosis is effectively treated by thoracic sympathectomy. Previous reports revealed that palmar skin temperature and perfusion increased on focal palmar regions after treatment. This study aimed to investigate the blood flow change over the whole palmar surface after the procedure. METHODS: Thirty patients with severe palmar hyperhidrosis were included for study. Each participant received measurement of palmar skin perfusion by a laser Doppler image scanner 1 day before and 1 day after surgery. Concomitantly, palmar skin temperature was recorded by a contact thermometer probe. One patient underwent intraoperative recording of palmar skin perfusion. RESULTS: Palmar skin perfusion and temperature increased significantly after thoracic sympathectomy. Intraoperative measurement performed for a patient showed a similar trend of increment of palmar skin blood flow. CONCLUSIONS: The global skin perfusion of palms can be analyzed in real time by the laser Doppler image scanner. This technique could be useful for analysis of blood flow changes in other body surface regions after thoracic sympathectomy.

Adolescent↗

PubMed2000

Needlescopic thoracic sympathectomy: treatment for palmar hyperhidrosis.

BACKGROUND: Open thoracic sympathectomy has been the established option for patients with essential hyperhidrosis. Recently, video-assisted endoscopic sympathectomy has provided a simple, safe, reliable, and cost-effective alternative to the earlier technique. With advances in instrumentation, performing the procedure through 2-mm and 3-mm needlescopic ports is now possible. The authors evaluate the effectiveness of so-called needlescopic thoracic sympathectomy for the treatment of primary hyperhidrosis. METHODS: Thirty five consecutive patients with a mean age of 24 years, including 23 men and 12 women, underwent bilateral needlescopic thoracic sympathectomies at the National University Hospital of Singapore. RESULTS: The mean operative duration was 56 minutes, and the mean hospital stay was 1.2 days. In no patient did Horner's syndrome or significant pneumothorax develop. The rate of success, defined as completely dry hands, was 97%. Two patients had unilateral recurrences that responded well to repeat needlescopic sympathectomies. We performed a total of 72 sympathectomies. CONCLUSIONS: Our study demonstrates that the use of miniature port access sites produces excellent medical and cosmetic results and is associated with a short hospital stay and low risk of complications.

Adult↗

PubMed1997

Thoracoscopic sympathectomy for upper limb hyperhidrosis: looking for the right operation.

BACKGROUND: Thoracoscopic sympathectomy is the most effective treatment for upper limb hyperhidrosis. However, this is offset by the occurrence of a high rate of side effects, such as embarrassing compensatory sweating. Anticipating that a technique that respects the sympathetic chain and divides only the rami communicantes may lead to fewer side effects, we assessed the technique described by R. Wittmoser, comparing it with conventional thoracoscopic sympathecomy. METHODS: A total of 240 thoracoscopic sympathectomies were performed in 124 patients suffering from upper limb hyperhidrosis. Fifty-four patients underwent a conventional sympathectomy (group TS), 62 underwent division of the rami communicantes with respect to the main trunk (group SS), and 8 underwent both procedures (group TS/SS) because of accidental division of the chain during dissection. The mean follow-up is 8 months. RESULTS: No recurrence was observed in group TS whereas six (5%) occurred in group SS (p < 0.05). The global rate of compensatory sweating was about the same in both groups: 72.2% in group TS and 70.9% in group SS. However, the rate of embarrassing or disabling compensatory sweating was significantly higher in group TS (50%) than in group SS (21%) (p < 0.001). CONCLUSIONS: Although selective division of the rami communicantes results in a significant decrease in the rate of disturbing side effects, it also leads to recurrences that are usually not observed at that level in patients treated with the conventional technique. Therefore other means of achieving the ideal operation should be explored, that is, a technique associated with a high success rate but a minimal number of side effects.

Adolescent↗

PubMed2006

[Thoracic sympathectomy in primary hyperhidrosis: patient satisfaction].

OBJECTIVE: To evaluate satisfaction among patients who underwent thoracic sympathectomy for primary hyperhidrosis and the possible complications after a minimum of 14 months after surgery. MATERIAL AND METHODS: We performed a retrospective study in 108 patients who underwent thoracic sympathectomy and who responded to all the questions asked in a telephone interview. The sample was composed of 21 men and 87 women, with a mean age of 29.73 years. In all patients, surgery was performed with general anesthesia in a single intervention. Special emphasis was placed on the degree of satisfaction (whether patients would recommend this type of surgery) and the possible negative effects or complications experienced by patients or attributed by them to the procedure. RESULTS: Patients were contacted a minimum of 14 months after the intervention. The most frequent complication was compensatory sweating (81.5%). Pain at the site of trocar insertion was reported by 6.5%. There were few immediate and long-term complications. The degree of satisfaction reached 90.7%. CONCLUSION: Video-assisted thoracic sympathectomy is safe and effective. Despite compensatory sweating, overall satisfaction was very high. However, satisfaction gradually decreased in the months after the intervention. Patients with hyperhidrosis with significant or principal axillary involvement could benefit from botulinic toxin administration as the first-line therapy.

Adolescent↗

PubMed1986

Treatment of primary hyperhidrosis.

Primary hyperhidrosis is a physically and emotionally distressing condition. Physicians should be aware of the various treatment modalities available for controlling or reducing the profuse sweating, which involves mainly the palms, soles, and axillas. The simplest methods, such as topical application of aluminum chloride, should be attempted first. If topical medications are ineffective, iontophoresis may provide relief, especially in patients with plantar or palmar involvement. When patients are unresponsive to other treatment options, surgical intervention may be warranted-excision of sweat glands in patients with axillary hyperhidrosis and upper thoracic sympathectomy in those with palmar involvement. Although excellent results have been reported, complications and resumption of sweating have occurred.

Administration, Topical↗

PubMed1997

Transthoracic video endoscopic electrocautery of sympathetic ganglia for hyperhidrosis palmaris: special reference to localization of the first and second ribs.

BACKGROUND: The surgical technique for transthoracic endoscopic sympathectomy varies from one to three skin incisions, room air to carbon dioxide pneumothorax, and destruction of the second (T2), third (T3), and fourth sympathetic ganglia to destruction of the T2 ganglion only. A knowledge of the surgical anatomy of the apex may help the surgeon to safely use this technique. METHODS: Forty-seven patients with palmar hyperhidrosis underwent video-assisted endoscopic electrocautery of the T2 and T3 ganglia with the use of one-lumen endotracheal tube for general anesthesia, one skin incision, and carbon dioxide pneumothorax. Surgical anatomy, palm temperature, and surgical results were analyzed. RESULTS: The first ribs of 23 patients were endoscopically visible and most of these first ribs were not as parallel to the second ribs as the third ribs were. The first ribs of the remaining 24 patients were palpable with a diathermy bar. In all but three patients with dense pulmonary adhesions, the distal end of the intrathoracic segment of the subclavian artery was seen to pierce the pleura at the upper border of the first rib. Ninety-one palms remain dry and 27 patients develop compensatory sweating in an average follow-up of 12 months. Excluding three patients whose sympathetic ganglia could not be electrocauterized because of severe pulmonary adhesions, 95% of the remaining 44 patients are satisfied with the results. CONCLUSIONS: Transthoracic video endoscopic electrocautery of the T2 and T3 ganglia for patients with palmar hyperhidrosis may yield excellent results if the first rib can be properly identified.

Adolescent↗

PubMed1999

Transthoracic endoscopic sympathectomy in the treatment of palmar hyperhidrosis--with emphasis on perioperative management (1,360 case analyses).

BACKGROUND: Primary palmar hyperhidrosis (PH) is very common, and can be disabling. Various surgical methods for endoscopic sympathectomy have been advocated. We present a simple and effective method of treating PH by means of transthoracic endoscopic sympathectomy (TES). METHODS: From July 1994 to May 1998, a total of 1,360 patients with hyperhidrosis palmaris underwent TES. There were 544 males and 816 females with a mean age of 23.1 years old (range, 5 to 60 years). All patients were placed in a half-sitting position under single-lumen intubational anesthesia. We performed the ablation of the T2 ganglion using either a 6- or 8-mm, 0-degree thoracoscope (Karl Storz Company, Germany) RESULTS: In these 1,360 patients, 2,715 sympathectomies were performed. TES was usually accomplished within 15 min. Surgical complications were minimal: six cases of pneumothorax (0.44%), four cases of segmental collapse of lung (0.29%), and two wound infections (0.15%). There was no surgical mortality. The mean postoperative follow-up period was 27.8 months. A total of 1,292 patients (95%) had highly satisfactory results, although 1,140 patients (84%) have developed compensatory sweating of the trunk and lower limbs. The affected area was the axillae, back, abdomen, lower limbs (16%, 82%, 52%, and 78%, respectively). The recurrence rates of PH were 0.4% in the first year, 0.6% in the second year, and 1.1% in the third year. CONCLUSIONS: TES is a simple, safe, and effective method of treating PH.

Adult↗

PubMed1997

The second thoracic sympathetic ganglion determines palm skin temperature in patients with essential palmar hyperhidrosis.

Sympathectomy of the second (T2) and third (T3) thoracic ganglion is frequently performed for essential palmar hyperhidrosis and occasionally performed, in addition to stellectomy, for idiopathic Raynaud's disease. The increased palm skin temperature after the operation probably results from increased skin perfusion. To determine whether it was possible to limit the extent of sympathectomy for these patients, we recorded palm skin temperature after electric stimulation of stellate, T2 and T3 ganglia, and after randomized electrocautery of T2 and T3 ganglia in 20 patients. We analyzed the statistics according to paired t-test with Bonferroni adjustment. We found that palm skin temperature decreases significantly after stellate stimulation. While rising significantly after destruction of T2 ganglion in the presence of intact T3 ganglion (P = 0.00001), palm skin temperature did not rise significantly after T3 destruction in the presence of intact T2 (P = 0.779). Following T2 and T3 destruction, however, palm skin temperature rose despite stellate stimulation. This suggests that T2 ganglion determines palm skin temperature while stellate and other upper thoracic ganglia may play a minor role, that T2 sympathectomy suffices for the treatment of essential palmar hyperhidrosis, and that sympathectomy for Raynaud's disease might skip stellectomy.

Adolescent↗

PubMed1999

Left stellate stimulation increases left ventricular ejection fraction in patients with essential palmar hyperhidrosis.

Left stellate stimulation increases cardiac contractility, heart rate, systolic blood pressure, and QT interval in experimental animals. To see if these changes occur in humans, we stimulated the left stellate ganglia with a monopolar coagulation power of 5 W in 10 patients with palmar hyperhidrosis, axillar hyperhidrosis, or both. We also stimulated the right stellate ganglia of the other 10 patients. The mean left ventricular ejection fraction (LVEF, measured with M-mode echocardiography), QT interval, heart rate and systolic blood pressure of the baseline were 54.72%, 403 ms, 65/min, and 115 mmHg, whereas those after 45 s of left stellate stimulation were 62.84%, 434 ms, 73/min, and 123 mmHg respectively. We compared these data with those of the baseline and the two-tailed P values were 0.005 for both LVEF and QT interval, 0.052 for heart rate, and 0.050 for systolic blood pressure respectively (Wilcoxon Matched-Pairs Signed-Ranks Test). The corresponding P-values for those of the right stellate stimulation were 0.721, 0.203, 0.260, and 0.326 respectively. All these suggest that the left stellate ganglia predominate the right ones in affecting LVEF, QT interval, heart rate and systolic blood pressure in humans, that left stellate stimulation increases LVEF and prolongs QT interval significantly, and that left stellate stimulation accelerates heart rate and elevates systolic blood pressure marginally.

Adult↗

PubMed2004

Does wrist nerve block influence the result of botulinum toxin A treatment in palmar hyperhidrosis?

Treatment of palmar hyperhidrosis with intracutaneous injections of botulinum toxin type A is painful, making anesthesia desirable. However, nerve blocks may be associated with reduced efficacy. In 20 patients with idiopathic palmar hyperhidrosis both palms were treated with intracutaneous injections of botulinum toxin type A after having randomly chosen one hand for anesthesia by median und ulnar nerve block and the other hand for cooling. There was no difference in efficacy of botulinum toxin A treatment between both palms but significantly greater injection pain after cooling compared with nerve block.

Adolescent↗

PubMed1999

Side-controlled intradermal injection of botulinum toxin A in recalcitrant axillary hyperhidrosis.

BACKGROUND: Although topical application of aluminium chloride is the most common measure against axillary sweating, severely affected patients often undergo surgical procedures that are expensive and may have considerable side effects. Recently botulinum toxin A (BT-A) has been reported as a potentially effective antihyperhidrotic agent. OBJECTIVE: Our purpose was to determine the therapeutic strength, safety, and mode of application of BT-A in severe axillary hyperhidrosis. METHODS: Intradermal injection of BT-A (Dysport) was given in an open left-versus-right side trial with each patient being his own control for initial efficacy, followed by treatment of the contralateral side. RESULTS: Seven days after initial treatment sweat production fell to below 10% of the untreated contralateral axilla as determined by gravimetry. Satisfaction was rated unanimously as "very good," the highest of 5 rankings. No side effects such as skin irritation or muscle weakness were noted in any patient. CONCLUSION: Intradermal injection of BT-A is a potent and well-accepted therapeutic option in patients with recalcitrant axillary hyperhidrosis.

Adult↗

PubMed2002

[Our experience in the treatment of hyperhidrosis of the upper limbs by video-assisted thoracoscopy: an analysis of our first 100 procedures].

Sympathectomy of the thoracic chain is an effective surgical procedure for treating axillary and palmar hyperhidrosis. The procedure has been performed with minimal invasion and good results in recent years through the use of videothoracoscopic surgery. This paper describes the technique and our experience with a series of 50 patients between 16 and 48 years old. The earliest approach was unilateral in successive operations. The procedure was later performed bilaterally, at first with the patients in sequential lateral decubitus positions and later in semi-seated position. Complications were 1 case of incomplete Claude-Bernard-Horner syndrome that resolved spontaneously two months after surgery; 1 failure when sympathectomy was performed without location of the chain, obliging rapid re-operation; laminar pneumothorax in 12% of the series; compensatory hyperhidrosis in 26%; 10% with chest pain due to intercostal involvement, resolving with time; and slight bleeding in 8%. Outcome was excellent, with complete disappearance of axillary and palmar perspiration. Patient satisfaction was 9.2/10 one year after surgery. Mean hospital stay was less than 36 h.

Adolescent↗

PubMed2004

[Thoracic sympathectomy: treatment for hyperhidrosis].

Hyperhidrosis is a benign functional anomaly which is highly stressful for the patient. Active management is required. Several medical options are available but are often ineffective. The thoracic sympathic system plays a fundamental role in propagating stimulation of sudoral gland secretion. Endoscopic thoracic sympatecomy thus provides a radical treatment for severe palmar and axillary hyperhidrosis. We describe the technique used in our unit and present results and possible complications. This method has been used by many teams for several Years and despite some differences, most confirm major patient benefit. Phenomena of transferred sudation are frequent by are usually not invalidating. Patients should however be informed of this possibility because the effect is often irreversible.

Endoscopy↗

PubMed1996

Hyperhidrosis treated by thoracoscopic sympathicotomy.

Hyperhidrosis of the palms, axillae and face has a strong negative impact on social and professional life. The existing non-operative therapeutic options seldom give sufficient relief and have a transient effect. A definitive cure can be obtained by upper thoracic sympathectomy. The traditional open surgical techniques are major procedures and few patients and surgeons have found that the risk--benefit consideration favoured surgery. Since 1987, the authors have divided the upper thoracic sympathetic chain on 1163 patients with a simple endoscopic technique by using standard urological equipment. A bilateral procedure takes less than 20 min and requires just one night in hospital. There have been no mortality or life-threatening complications. Ten patients (< 1%) required intercostal drainage because of haemo- or pneumothorax. Horner's syndrome occurred in four cases. Primary failure occurred in 23 cases (< 2%) and 24 (< 2%) developed recurrent symptoms. The patients with failure and recurrence were successfully reoperated on and only three have required a third operation. At the end of postoperative follow-up (median 31 months) 98% of the patients were satisfied. Endoscopic transthoracic sympathicotomy is an efficient, safe and minimally invasive surgical method for the treatment of palmar, axillary and facial hyperhidrosis.

Adolescent↗

PubMed1998

Primary palmar hyperhidrosis presenting with unilateral symptoms: a report of two cases and review of the literature.

Two cases of primary palmar hyperhidrosis are presented. T2-T3 sympathetic ganglionectomy of the affected side completely alleviated perspiration of the palms, but oversweating of the contralateral palms appeared a few weeks later. A similar sympathetic ganglionectomy of the second side, 1 month and 1 year later, resulted in renewed oversweating of the palm on the first operated side within 3 months of the second operation. During the same period, 127 other patients with primary palmar hyperhidrosis underwent a bilateral upper dorsal sympathectomy, though the condition did not recur in any of these patients. The possible mechanism(s) of why overperspiration of the second hand developed after the first sympathectomy in these two patients, and why it recurred in the first hand after the second operation are examined, but remain obscure.

Adult↗