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Dr
Senior Consultant Surgeon
Minimal Access Surgery
Email:
surgerytimes@gmail.com
Tel: ++91-11-29871280 / 29871202
Mobile
Number ++91-9811082425
In New Delhi, India, Minimal Access Surgery, Minimally Invasive Surgery, Thoracoscopic Surgery, VATS ( Video Assisted Thoracic Surgery ), and ETS ( Endoscopic Thoracic Sympathectomy ) are terms used to describe the modality of procedure that is done to interrupt the sympathetic nerve chain as a treatment for Hyperhidrosis of face, palms and axilla ( arm pit ).
Following is a brief introduction of the disease, treatment options and views of some of the experienced surgeons around the world. I hope it answers most of the questions. If there are any unanswered questions or doubts, please email to me at surgerytimes@gmail.com .
Warning!! Please note that the management of this
disease is complicated and should be carefully planned with an expert.
Introduction
Hyperhidrosis, is sweating in excess of that required for normal thermoregulation. It is a condition that usually begins in either childhood or adolescence. Although any site on the body can be affected, the sites most commonly affected are the palms, soles, and axillae.
The condition often causes great emotional distress and occupational disability for the patient, regardless of the form. There is very little awareness of this problem and hence it leaves the patient totally baffled. Parents, friends, teachers, colleagues and often doctors think that it is because the person is " nervous " and as time passes, the person also starts believing the same. It leads to lack of confidence, isolation, introversion, shyness, non-sporty personality etc. It is important to note that these behavioral changes are a result of the sweating and NOT the cause of it.
It is unfortunate that so many people ( 1: 1000 as per a US survey ) who can be cured of this dreadful problem are suffering from it simply because of lack of awareness amongst public and even doctors.
The following are the common problems faced by my patients who have come to me for treatment
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Inability to shake hands with clients, seniors, colleagues leading to embarrassing start of a meeting and awareness of this prevents them from confidently dealing with people.
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Key board and mouse getting wet while using computer for professional reasons. ( Also camera, sport racket, mechanical instruments etc)
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Wetting of answer sheets during exam.
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Reluctant to get married.
Severe cases of hyperhidrosis may adversely affect the patient's quality of
life by causing great emotional distress, social embarrassment, and
work-related disability (due to palmoplantar hyperhidrosis).
Palmoplantar sweating may result in irritation of the affected skin,
ultimately leading to chafing.
Axillary hyperhidrosis may be malodorous, causing social
embarrassment.
Hyperhidrosis exists in 2 forms:
1. Generalized hyperhidrosis may be
secondary to numerous conditions including the following:
- Neurologic or neoplastic
diseases
- Metabolic
disorders or processes (eg, thyrotoxicosis,
diabetes mellitus, hypoglycemia, gout, pheochromocytoma,
menopause)
- Febrile
illnesses
- Use of
medications (eg, propranolol,
physostigmine, pilocarpine,
tricyclic antidepressants, venlafaxine)
- Chronic
alcoholism
- Hodgkin
disease or tuberculosis (in nocturnal hyperhidrosis)
2. Localized hyperhidrosis
( in which it affects the palms, feet, face or armpits either
individually or in a combination ).Unlike sweating on the remainder of the body,
sweating on the palms and feet is controlled solely by the cerebral cortex and
is responsive to emotional stimuli rather than to temperature stimuli. Both
emotional and thermoregulatory stimuli control sweating in the axillae. Therefore, palmoplantar hyperhidrosis, unlike generalized hyperhidrosis,
does not occur during sleep or sedation.
Prognosis
Hyperhidrosis is difficult to treat effectively.
With the newer treatment
modalities now available, the patient has numerous options and is offered a
better prognosis.
Patient Education
Patients should be
educated regarding all of the treatment options, including their corresponding
complications and costs.
Investigating a person of hyperhidrosis
Search for primary causes if generalized hyperhidrosis is noted.
Important laboratory studies may include the following:
- Thyroid
function tests may reveal underlying hyperthyroidism or thyrotoxicosis.
- Blood
glucose levels may reveal diabetes mellitus or hypoglycemia.
- Urinary catecholamines may reveal a possible pheochromocytoma.
- Uric acid
levels may reveal gout.
- A Mantoux test can be performed to screen for
tuberculosis.
- Chest
radiography may be used to rule out tuberculosis or a neoplastic
cause.
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How do I know this is hyperhidrosis and not nervousness / underconfidence?
While every one has increased sweating during stress, it is hyperhidrosis when sweat starts to drip.
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Will it go away as I grow older?
Possible, but one cannot be sure. Ask your parents if they too suffered during their youth and if it got better.
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Is there a local treatment?
Local solutions, antiperspirants, iontophoresis, botulinum toxin are temporary relief measures.
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When is surgery required?
When your quality of life is getting affected by the problem.
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What are the types of surgery? Which one is suitable for me?
ETS is the treatment of choice and gold standard with which all other methods are compared.
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How much does the treatment cost?
About $2000 in India, $8000 in Taiwan, $16,000 in USA ( figures vary from centre to centre )
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Is surgery a permanent cure? What are its side effects?
Yes it is a permanent cure with a success rate close to 98% as per most reported studies and data. Some patients can get compensatory sweating ( read below )
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Is it done under general or local anesthesia? How long does one stay in the hospital?
I do it under general anesthesia and patient stays for 12- 24 hours after surgery ( depends on individuals )
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What is compensatory sweating? Who gets it?
The sweat that is reduced, gets re-distributed to the rest of the body. Most patients have not been bothered by this complaint but international figures and data suggest upto 60% patients can have this. This is the main side effect of the surgery and does not have any known remedies.
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Is the surgery reversible in case I do not like it?
ETS- clipping is theoretically reversible, but no one can assure it.
Therapy can be challenging for both the patient and the
physician. Both topical and systemic medications have been used. Other
treatment options include iontophoresis and botulinum toxin injections. (
WARNING:
Following treatment should not be tried by a patient without recommendation of
a specialist doctor )
1. Topical agents
include topical anticholinergics, boric acid, 2-5%
tannic acid solutions, resorcinol, potassium
permanganate, formaldehyde (which may cause sensitization, glutaraldehyde,
and methenamine.
Drysol (20% aluminum chloride hexahydrate
in absolute anhydrous ethyl alcohol is usually the most effective topical
agent. Drysol should be applied nightly on dry skin
with or without occlusion until a positive result is obtained, after which the
intervals between applications may be lengthened. To minimize irritation, the
remainder of the medication should be washed off when the patient awakes, and
the area may be neutralized with the topical application of baking soda.
2. Systemic agents
used to treat hyperhidrosis include anticholinergic medications. Anticholinergics
such as propantheline bromide, glycopyrrolate,
oxybutynin, and benztropine
are effective because the preglandular
neurotransmitter for sweat secretion is acetylcholine (although the sympathetic
nervous system innervates the eccrine sweat glands).
The use of anticholinergics may be unappealing
because their adverse effect profile includes, blurry
vision, dry mouth and eyes, difficulty with urination, and constipation. In
addition, other systemic medications, such as sedatives and tranquilizers, indomethacin, and calcium channel blockers, may be
beneficial in the treatment of palmoplantar hyperhidrosis.
3. Iontophoresis
was introduced in 1952 and consists of passing a direct current across the skin.
The mechanism of action remains under debate.
4. Botulinum
toxin injections are effective
because of their anticholinergic effects at the
neuromuscular junction and in the postganglionic sympathetic cholinergic nerves
in the sweat glands.
In palmar hyperhidrosis,
50 subepidermal injections of 2 mouse units per palm
(total 100 mouse units per palm) results in anhydrosis
lasting 4-12 months (Shelley, 1998). Each injection produces an area of anhydrosis approximately 1.2 cm in diameter. The only
adverse effect is mild transient thumb weakness that resolves within 3 weeks.
Noted adverse effects include minor muscle weakness at the toxin-treated sites,
which usually resolves after 2-5 weeks. Injections of botulinum
toxin must be repeated at varying intervals to maintain long-term results.
In addition to pharmacologic therapy, other treatments
include surgical sympathectomy, surgical excision of
the affected areas, and subcutaneous liposuction. Each modality has been used
effectively.
1. Sympathectomy has been used as a permanent effective treatment since 1920. Usually, it is reserved for the final treatment option. Sympathectomy involves the surgical cutting / clipping of the sympathetic chain responsible for hyperhidrosis. This leads to control of sweating and does not affect sensory touching or muscle function.
The second (T2) and third (T3) thoracic ganglia are
responsible for palmar hyperhidrosis,
the fourth (T4) thoracic ganglia controls axillary hyperhidrosis,
and the first (T1) thoracic ganglia controls facial hyperhidrosis.
Two surgical approaches are available:
- an open
approach and
- a newer thoracoscopic / ( ETS (endoscopic
thoracic sympathectomy / VATS ( video assisted
thoracic surgery ) approach. (All three names are for the same procedure).
The
techniques of open surgical access to the upper thoracic sympathetic chain are
multiple, but they all share the drawbacks of being major surgical procedures
with considerable risk of complications and sizable scars. There has therefore
been an understandable reluctance of both doctors and patients to adopt this
method in the treatment of hyperhidrosis. Thoracic surgeons utilize the following surgical
approaches:
Transthoracic (large open chest incision)
Transaxillary (through the armpits with a
open incision)
Anterior transthoracic (through the front of the chest with a large
incision).
Recently, the endoscopic approach
has become favored because of its improvements in terms of complications,
surgical scars, and surgical times. Thoracoscopy was first performed in 1910,
and the first report describing this method of performing sympathectomy
appeared in 1942. In
Chain picked below T2 Divided with cautery Nerve of Kuntz Skin cut glued together
CLICK HERE to see a video clip of the above procedure.
In 1954, an Austrian surgeon pioneered the
technique of Endoscopic Upper Thoracic Sympathectomy (ETS). Subsequent improvements in the science
of optics and instrumentation led to the refinement of the ETS procedure by
creating smaller instruments that can visualize and clip the sympathetic
nerves.
The sympathectomy
procedure has evolved over the past 60 years. What began as an open chest
operation is now being performed with small scopes and cameras. The sympathetic
nerve trunks are no longer removed or destroyed, but instead are now clamped.
The new procedure is called an Endoscopic Transthoracic Sympathetic Blockade (ETB) with Metallic
Clips. It is also referred to as an Endoscopic Transthoracic Sympathectomy -
Clip (ETS-C). The terms ETB and ETS-C are interchangeable and mean the same.
Complications are possible with this endoscopic treatment option; these include compensatory sweating (induction of sweating in previously unaffected areas of the body), gustatory sweating, pneumothorax, intercostal neuralgia, Horner syndrome (in case of T1 surgery), recurrence of hyperhidrosis (due to left behind nerve of Kuntz or aberrant nerves) , and the sequelae of general anesthetic use. Of 850 patients who underwent endoscopic transthoracic sympathectomy, 55% had compensatory sweating (mostly on the trunk), and 36% had gustatory sweating (Drott, 1995). In a similar study of 72 patients who underwent transthoracic endoscopic sympathectomy (T2 or T2 and T3) for palmar hyperhidrosis, the success rate was 93%; compensatory sweating occurred in most of the patients within 1 month after surgery, and gustatory sweating occurred in 17% (Lai, 1997).
For more on compensatory sweating, CLICK HERE
2. Surgical
excision of the affected area (identified
with iodine starch testing) removes the appropriate sweat glands, thereby eliminating
sweating. This technique is particularly useful in axillary hyperhidrosis.
Subcutaneous liposuction is another means of removing the eccrine sweat glands responsible for axillary hyperhidrosis. Compared with classic surgical excision, this modality results in less disruption to the overlying skin, resulting in smaller surgical scars and a diminished area of hair loss.
In the authors experience of Thoracoscopic Surgery over 14 years, over 250 patients have undergone this procedure of which about 50 have had the treatment in the last 2 years ( probably because of increased information available on the net and easier net access in India ). Average age has been 25 years and 90% male patients. Most patients have been IT professionals ( this may be due to easier internet access for them ). So far the improvement of palm sweating has been 100% ( this figure however should not be seen as a guarantee by prospective patients as the world wide results are about 95%). Compensatory sweating was seen in 60% patients but none have been troubled by it to the extent that they regretted having had the surgery). Of the 26 patients who were suffering from palm, feet and armpit sweating ( all 3 ), 21 showed cure of all 3 problems while 5 had benefit of palms only and little change in the feet and armpits. 2 patients had additional face sweating, 1 had improvement of palm and face while the other showed improvement of palm only.
On a lighter note: 16 patients underwent the procedure before their wedding and in 1 case patient's wife said that they were planning their 2nd honeymoon !!
VIEWS FROM OTHER EXPERT CENTRES
1. Dr Chien-Chih Lin, from the Department of surgery, Taiwan, said the following in an article published in European Journal of Surgery
Thoracoscopic T2-sympathectomy or
sympathicotomy (without removal of ganglia) is
considered the best treatment for hyperhidrosis.
However, the main disadvantage of this procedure is its irreversibility. As
sympathetic nerve regeneration is impossible to control after sympathectomy, this usually leads to compensatory sweating
over the trunk or back – a consequence some patients regret, even to the extent
of preferring the original sweaty hands.
Denny-Brown and Brenner proved
that without transecting the nerve trunk, nerve conduction could be interrupted
by a compression force of more than 44 grams. The present endoscopic
clips exert a force of approximately 150 grams. This force is obviously high
enough to block the transmission of sympathetic impulses. Based on this
principle, thoracoscopic T2-sympathetic blockade by endoscopic
clipping was performed for hyperhidrotic patients.
2.
Dr Garza from Texas,
A
sympathetic blockade is a procedure where clamps are applied to specific nerve
trunks. These nerve trunks carry the nerve signal from the brain to the face,
hands, underarms or feet, which then causes excessive sweating. Thus, the
sympathetic nerves in the chest are not the direct cause of hyperhidrosis,
but transmit the nerve signals that begin the sweat response. In cases of
sweating of the hands, underarms, scalp and face as well as facial blushing,
the nerves that control these areas are located in the chest. The nerves spread
out like a spider web to each location.
Recommendations:
1. The first thoracic trunk and ganglion
(T1) control the sweat response mostly in the face, then in the hands, and ,to
a lesser extent, in the underarms. The first ganglia (also called the Stellate ganglia) also control the
eyelid and pupil response. This ganglion should be spared.
2. The second trunk (T2) controls the sweat response in the hand and face and facial blushing. It is the preferred nerve to be clamped to control facial blushing and sweating. It also affects sweating of the hand.
3. The third thoracic trunk (T3) also affects facial and hand sweating.
4.
The fourth thoracic trunk (T4) affects hand and underarm sweating.
Effectiveness of Sympathectomy
for Hand Sweat
The suggesated technique spares the 2nd and 3rd sympathetic nerve trunk and clamps only the 4th nerve trunk. This is effective in eliminating sweating of the hands and underarms in approximately 96% of patients who have this procedure and leads to a marked reduction in severe postoperative compensatory sweating which occurs during the standard T2 or T2-T3 sympathectomy.
Effectiveness of Sympathectomy
for Axillary (Armpit) Sweat
The
latest recommendation for treating severe sweating of the underarms is to apply
small titanium clamps across the T4 nerve trunk. The
effect is immediate cessation of underarm sweating in 96% of all patients.
The
T4 sympathectomy is known for a marked reduction in
severe compensatory sweating. The reason for this change in compensatory
sweating is because clamping the 2nd nerve trunk also stops sweating in the
face and head. The face and head alone are responsible for over 44% of all heat
released from the body. Once the T2 nerve trunk is clamped or cut, that 44% of
body heat loss has to be released elsewhere throughout the body and will create
more sweating on the trunk, groin, buttocks and legs.
Effectiveness of Sympathectomy
for Facial and Scalp Sweat
An
ETB for facial and scalp hyperhidrosis is about 95%
to 98% successful. The T2 nerve trunk is clamped and is effective in 98% of the
time. The problem with a T2 or T3 sympathectomy is
that it will often lead to the side effect of compensatory sweating.
Effectiveness of Sympathectomy
for Facial Blush
An ETS is successful in treating facial blush in about 85% of all patients. It is recommended that titanium clamps be applied across the T2 nerve trunk. In the remaining 15% of cases, the intense blushing returns. The theoretical reason for failure in these cases is because the T1 nerve trunk or ganglion may have more control over the facial blushing than the T2 nerve trunk. The T1 nerve trunk, however, should not be disturbed because it will lead to paralysis of the eyelid muscle and cause a droopy eyelid.
Effectiveness of Sympathectomy
for Foot Sweat
Although
approximately 50% of patients who undergo an ETS for hand sweating will benefit
from the elimination or significant reduction of foot sweating, this procedure
is not recommended to treat primary foot hyperhidrosis.
Those who wake up after surgery with dry feet may be disappointed to discover
that the foot sweating can recur within the first week to several years later.
The only known surgical treatment of foot sweating is to perform a lumbar sympathectomy. However, this procedure may cause the side
effect of urinary incontinence in women and retro-grade ejaculation in men