Thoracoscopic cervicothoracic sympathectomy: an eight-year experience*
(Portuguese PDF version)

Paulo Kauffman1, José Ribas Milanez de Campos2, Nelson Wolosker3, Sérgio Kuzniec4, Fábio Biscegli Jatene5, Pedro Puech Leão6

1. PhD and Assistant Professor, Course of Vascular Surgery, School of Medicine, Universidade de São Paulo (FMUSP).
2. PhD and Assistant Physician, Division of Thoracic Surgery, Hospital das Clínicas - Heart Institute (HC-INCOR), FMUSP.
3. Professor, Course of Vascular Surgery, FMUSP.
4. PhD and Vascular Surgeon.
5. Head of the Division of Thoracic Surgery of HC-INCOR. Professor, FMUSP.
6. Professor, Course of Vascular Surgery, FMUSP.

*This study was conducted in the Course of Vascular Surgery of FMUSP, at the Division of Thoracic Surgery of HC-INCOR and at Hospital Albert Einstein

Correspondence:
Dr. Paulo Kauffman
Av. Nove de Julho, 3229/709
CEP 01407-000 - São Paulo - SP
Tel.: +55 11 3887.8887
Fax: +55 11 3051.6447
E-mail: pauloka@attglobal.net

ABSTRACT

Objective: To present and discuss our eight-year experience with video-assisted cervicothoracic sympathectomy.

Methods: 388 patients were submitted to surgery (240 females): 378 cases of hyperhidrosis, four of thromboangiitis obliterans, four of causalgia and two of long QT syndrome. Resection of the sympathetic chain was performed in the first 45 patients of the series. Ablation was performed using electrocauterization in 251 patients and harmonic scalpel in the other 92 patients. In cases of palmar hyperhidrosis, the resection or ablation was restricted to T2. When this was associated with axillary hyperhidrosis, it was restricted to T2 and T3, and in purely axillary hyperhidrosis, T3 and T4. In the cases of thromboangiitis obliterans and causalgia, the resection or ablation was restricted to the cervicothoracic ganglion, T2 and T3, and in the long QT syndrome, T1 to T5 on the left side.

Results: No deaths occurred, and there was no need to resort to open surgery for the procedures in any patient. The follow-up period ranged from one to 60 months (mean of 12.42 ± 8.3). Excellent or good results were obtained in 90% of the patients, including 10 patients who presented organic diseases. The main complication in the cases of hyperhidrosis was compensatory hyperhidrosis, which occurred moderately to severely in 84% of the patients. This was a reason for regretting the surgery among 4% of the patients.

Conclusion: video-assisted cervicothoracic sympathectomy is a simple, effective and safe method for the treatment of hyperhidrosis and selected cases of severe ischemia of the hand, causalgia and long QT syndrome.

Key-words: sympathectomy, hyperhidrosis, video-assisted surgery
Palavras-chave: simpatectomia, hiperidrose, cirurgia vídeo-assistida.

J Vasc Br 2003;2(2):98-104

Until the 1980s, the axiom "great surgeons, ample incisions" was quite common. However, as Medicine is a science in which truths have a short "life", this idea was abandoned in the 1990s, when the so-called minimally invasive surgeries were introduced. This was possible thanks to the breakthroughs in endoscopic surgeries.

Thoracoscopic cervicothoracic sympathectomy is not recent. It was used by Kux,1 in Austria, in 1951, but was inexplicably rejected by most surgeons at that time, even after good results in the treatment of palmar hyperhidrosis in a significant number of patients were reported by Kux2 in 1978.

Few authors employed thoracoscopy in the 1980s for sympathetic denervation of upper extremities.3-6 With the development of optics and surgical materials for endoscopic surgeries in the late 1980s, thoracoscopic cervicothoracic sympathectomy began to be used as a method of choice by a considerable number of surgeons, especially in Asia and in Europe.7-28 The introduction of video assistance in this type of surgery, initially by Kao,12 encouraged its acceptance and development. Therefore, since it proved safe, easy to perform and was increasingly accepted by patients, video-assisted thoracoscopic cervicothoracic sympathectomy became widely used.

In 1995, we added this technique to the syllabi of the courses of Vascular Surgery and Thoracic Surgery of the School of Medicine of Universidade de São Paulo, using the experience of the first one in sympathectomy and of the second one in video-assisted thoracoscopy for the treatment of pleural and pulmonary diseases; then we began to use video-assisted thoracoscopic cervicothoracic sympathectomy.

The aim of the present study is to describe the technique used by us and show our results.


PATIENTS AND METHODS

Between October 1995 and September 2002, 388 patients aged from 3 to 70 years (mean of 26.8 ± 10.5) were operated on, of whom 240 (62%) were females.

Palmoplantar hyperhidrosis was reported by 217 (55.9%) patients, palmoplantar and axillary hyperhidrosis by 95 (24.4%), pure axillary hyperhidrosis by 60 (15.4%), craniofacial hyperhidrosis and/or facial blushing associated or not with palmar hyperhidrosis by 25 (6.4%); four (1%) suffered from thromboangiitis obliterans with severe ischemia of the hand, four (1%) had posttraumatic pain syndrome (causalgia) and two (0.5%) had long QT syndrome.

Most patients with hyperhidrosis (325) had been previously submitted to some kind of conservative treatment, but to no avail.

In the first five patients of the series (affected by hyperhidrosis), sympathectomy was bilateral, but performed in two different moments, at an interval of four to five weeks in between. The same procedure was adopted in another seven patients with hyperhidrosis who showed consistent lung adhesions, whose correction resulted in bleeding and maintenance of the pleural drain postoperatively. All the other patients (366) with hyperhidrosis underwent one-time bilateral thoracic sympathectomy, in a sequence, starting with the left hemithorax. One patient was submitted to bilateral lumbar sympathectomy six months after sympathetic denervation of upper extremities due to the severity of plantar hyperhidrosis. In patients with thromboangiitis and causalgia, cervicothoracic sympathectomy was unilateral because clinical manifestations were observed in one limb. In two patients with long QT syndrome, the surgery was performed on the left side only.


Surgical technique

General anesthesia with endotracheal intubation was used in 378 (97.4%) patients, using double-lumen catheter in 219 and of a simple catheter in 159; 10 (2.6%) patients were operated on under epidural anesthesia (T4/T5 level) and sedation.

The patients were placed supine, in a half-sitting position, with their trunk elevated at approximately 45°, with their arms abducted at 90°, leaning on the operating table side rails, and with a small pad under their shoulders in order that the armpits could be anteriorly positioned, thus facilitating the handling of surgical tools.

A small incision of 0.5 to 1 cm in length was made at the height of the fourth or fifth intercostal space, in the anterior axillary line, for the introduction of the video camera and another same-size incision was made in the mid-axillary line, at the height of the second intercostal space, through which the electric or harmonic (ultrasonic) scalpel was introduced in order to section and thermally ablate the sympathetic chain in a variable length according to the patient's clinical condition (Table 1).

click hereTable 1 - Clinical conditions and extension of the resected or sectioned and cauterized sympathetic chain

Clinical conditions (T = thoracic sympathetic ganglion)
Palmar hyperhidrosis T2
Hyperhidrosis and facial blushing T2
Palmar and axillary hyperhidrosis T2 T3
Isolated axillary hyperhidrosis T3 T4
TAO and posttraumatic pain syndrome (causalgia) T2 T3 T4 + cervicothoracic ganglion
Long QT syndrome T1 T2 T3 T4 to the left

 

Resection of the sympathetic chain was carried out in the first 45 (11.6%) patients of the series, with three incisions in each hemithorax using the technique previously described.29 Later on, thermal ablation, by way of electrocoagulation, was performed in 251 (64.7%) patients, and more recently, since September 2001, we used the harmonic scalpel in 92 (23.7%) patients for the section and thermal ablation of the sympathetic trunk.

At the end of surgery, the lung was reexpanded under direct vision at the same time air was aspirated from the pleural space by a catheter, which was often removed before skin suture, made with intradermal stitches. Chest x-ray was routinely taken in the immediate postoperative period in order to confirm the total expansion of the lungs. The patients were reassessed after seven and 30 days and at approximately six months thereafter.

RESULTS

Of 388 patients, 372 (95.9%) recovered uneventfully and were discharged one day after the surgery, 15 (3.9%) were discharged after 48 hours and only one (0.2%) was kept in hospital for 72 hours.

The postoperative follow-up ranged from 1 to 60 months (mean of 12.42 ± 8.3). Given the final result, 311 (80.2%) patients, including 10 who did not have hyperhidrosis, showed to be totally satisfied with the surgery; 40 (10.3%) were moderately satisfied, without sweating in the regions of reference, but still complained of compensatory hyperhidrosis, while 37 (9.5%) were not satisfied, and complained of little improvement and especially of intense compensatory hyperhidrosis. In the latter group, only 15 (4%) patients regretted undergoing surgical intervention.

Therefore, we may say that 351 (90%) patients obtained satisfactory results, including those with organic diseases. The four patients with thromboangiitis obliterans reported improvement of the pain, and the ischemic injuries in fingers healed totally or partially in the follow-up period. Likewise, the four patients with causalgia showed improvement of symptoms and the two patients with long QT syndrome had their heart condition stabilized.

Improvement of plantar hyperhidrosis was observed in 58% of the patients with palmoplantar and both palmoplantar and axillary hyperhidrosis.

Excessive sweating recurred in 22 (7%) patients in the palmoplantar and palmoplantar and axillary groups and in seven (11%) in the axillary hyperhidrosis group. Among these patients, eight were successfully reoperated up to six months after the first surgery.

The main complication of thoracic sympathectomy in cases of hyperhidrosis was compensatory sweating, which often occurred in the abdomen, back, and thighs, and whose intensity was regarded as moderate or intense in 241 (64%) patients, consisting of compensatory hyperhidrosis.

Other postoperative complications observed in this series included: reduced muscle strength or arm paresthesia due to brachial plexus praxis in 17 (4.3) patients; pneumothorax in nine (2.3%), seven (1.8%) of which required pleural drainage; pulmonary atelectasis in five (1.2%); superficial phlebitis in two; intense pain at the trocar site in two; intercostal vein bleeding in one. Unilateral Horner's syndrome was observed in four patients surgically treated for hyperhidrosis, and was transient in two and permanent in the other two.

Although pain in the anterior thoracic region was not systematically reported, it was present in most patients for two to three weeks, requiring the prescription of painkillers, but resolving spontaneously.

There was no need to switch to open surgery and no deaths occurred.

DISCUSSION

Currently, cervicothoracic sympathectomy has restrictive and precise indications: the major indication is the treatment of patients with palmar hyperhidrosis, and is also useful in cases of isolated or associated axillary hyperhidrosis.30 Patients with arteritis, especially thromboangiitis obliterans, with distal artery occlusion, ischemic digital lesions and local pain poorly controlled with common painkillers, may benefit from sympathectomy.31-32 In complex regional pain syndrome, aka causalgia or reflex sympathetic dystrophy, refractory to conservative treatment with drugs, physical therapy and sympathetic block, sympathetic denervation may be indicated and has shown to be satisfactory.33,34 In Raynaud's phenomenon, sympathectomy is indicated in those rare cases which, despite appropriate clinical treatment, continue to show intense symptoms or unhealing trophic digital lesions.16,32 However, in patients with vasospastic manifestations in the upper extremities, the results of an intervention are temporary, with recurrence of vasospastic episodes in the short term, thus leading some authors to contraindicate cervicothoracic sympathectomy in these cases.35,36 Craniofacial hyperhidrosis is a less frequent indication for the procedure; but results are satisfactory and persistent.37,38 Patients with long QT syndrome, irresponsive to clinical treatment, can also benefit from this technique.39,40 Sympathectomy may also be indicated in selected cases of intractable angina pectoris, with diffuse coronary disease without indication for angioplasty or any type of arterial repair, or in those previously operated on but without clinical and surgical conditions to be reoperated.41,42

In order for sympathetic denervation of upper extremities to be more complete and long-lasting, it should include the ablation of the cervicothoracic ganglion, T2 and T3.32,43-45 This practice necessarily causes the development of Claude Bernard-Horner sign, but avoids the incomplete denervation of the limb by means of communicating branches of the first thoracic ganglion, interrupts Kuntz nerves and prevents possible functional connections with denervated cervicothoracic ganglion cells.31,46 Until 1980, this was the only practice adopted at Hospital das Clínicas de São Paulo by the Division of Vascular Surgery, regardless of the reason for surgical indication.31,46 Nevertheless, if this procedure is necessary in cases of organic diseases, it may unnecessary in patients with benign functional manifestations such as palmar hyperhidrosis. In this situation, the preservation of the upper pole of the cervicothoracic ganglion, or of the whole ganglion, with ablation of the sympathetic chain, including T2 and T3, or only T2, has yielded satisfactory results.2126,47-49 For this reason, from the 1980s onwards, we have not resected the cervicothoracic ganglion in cases of palmar hyperhidrosis, and our results have been uniformly acceptable. However, through a supraclavicular access, the cervicothoracic ganglion was a point of reference for the identification of the sympathetic chain, and the simple surgical manipulation in its neighborhood was enough for the development of Claude Bernard-Horner sign, as reported by other authors.18 This complication was usually transient, but it surely caused problems to the patient.

Video-assisted thoracoscopy has some advantages over conventional open surgeries, as it is less aggressive, provides excellent anatomic exposure and magnified visualization of structures under perfect lighting, factors that facilitate the identification and resection of the sympathetic chain, with low morbidity, great cosmetic results and short hospital stay.50 Although the intervention can be conducted with a 2-mm optics, some limitations exist that interfere in the surgery, such as a narrow field of view and not fully appropriate illumination.51 We often use a 5-mm optics, but we are not sure that the cosmetic results and necessity for analgesia are different from those obtained through smaller incisions.

Insufflation of carbon dioxide into the pleural space has been used at some centers for improvement of surgical access. However, this practice is not risk-free and may cause cardiovascular disorders, even with the use of gas at restricted pressure.52 To avoid this problem, we have preferred to use open pneumothorax, which has proven to be quite satisfactory.

The improvement of plantar hyperhidrosis observed in more than 50% of our patients was also reported by other authors.16,21 There is no plausible physioanatomical explanation for this. Perhaps the reduction of stress by palmar anhidrosis obtained with the surgery, resulting in better emotional balance, has a positive effect on plantar hyperhidrosis.16 We do not agree with the practice of Duarte & Kux53 of extending sympathetic denervation up to T7 in order to improve plantar hyperhidrosis, since, anatomically, preganglionic fibers responsible for the innervation of lower limbs enter the sympathetic chain from T10 to L2, descending for synapse at L4, where most postganglionic fibers that incorporate into the branches of the sacral plexus originate for innervation of the lower extremity.32 Thus, the extension of resection proposed by these authors would only aggravate compensatory hyperhidrosis.

Thermal ablation of the sympathetic chain has been chosen by most authors as its results have been quite acceptable, nearly as good as those of resection.54 In addition, thermal ablation is a simpler procedure, with fewer complications and shorter duration. The use of a harmonic scalpel provides a cleaner surgical field, with less tissue fulguration and less smoke emission.

Compensatory hyperhidrosis is the major complication of sympathetic denervation in patients with hyperhidrosis, with a reported rate between 30 and 75%.27 In our series, this occurred in 64% of the patients, being moderate in 28% and intense in 36%. Probably, it represents the body's thermoregulatory response.49 It is more uncomfortable in the hot season, during physical exercises and in hot and damp work environments. It may decrease with time or the patient learns to live with it.55 Although frequent, it cannot be prevented. Some authors believe that a more economic resection of the sympathetic chain may attenuate compensatory hyperhidrosis.27 Nevertheless, the simple ablation of T2 to eliminate hand sweating has not minimized this complication in a significant way.21,26

In order to mitigate compensatory hyperhidrosis, Gossot24 selectively resected the communicating branches from T1 to T4. With this technique, the complication was minimized, at the expense of incomplete denervation of the limb, with recurrent hyperhidrosis in a considerable number of patients.28

Horner's syndrome, a complication of the surgery in cases of hyperhidrosis, albeit infrequent, has been reported in most articles and results from the direct or indirect injury to the cervicothoracic ganglion by heat transmission or excessive traction of the sympathetic chain during dissection or thermal ablation. In our series, we observed unilateral syndrome in four cases, which was temporary in two and permanent in the other two cases. The amplified visualization of anatomic structures, and better identification of the second costal arch provided by video-assisted thoracic sympathectomy, when performed by an experienced surgeon, who manipulates the sympathetic chain carefully and delicately, helps reduce the incidence of this complication.

Potentially serious or even lethal complications, such as injury to the subclavian artery, to the brachial plexus, pseudoaneurysm with extensive hemothorax, cerebral edema and cardiac arrest, are rare, but have been reported.50,56 Lai et al.57 reported relevant sinus bradycardia that lasted for over two years and required pacemaker implantation. Tanaka et al.58 verified that the minimal heart rate after the surgery depends on that which was observed preoperatively at rest. They recommended careful monitoring of any patient with a heart rate below 60 bpm in the preoperative period.

Resympathectomy has been carried out successfully.59 Among several causes for failure, we have: anatomic variations in the sympathetic chain, technical failure, consistent pleural adhesion, aberrant vessels or excessive adipose tissue over the chain and possible nerve regeneration. In our patient population, we noted that some patients who underwent resympathectomy showed sparse pleural adhesion, which would not invalidate surgical indication. All of them had good results and the main cause of primary failure was inadequate surgery. It should be underscored that resympathectomy requires extra care due to the increased risk of Horner's syndrome, caused by the retraction of the sympathetic chain after the first surgery. Nerve regeneration is rare,60 and we believe that recurrence of excessive sweating can be crucially prevented by an initial surgery that uses an appropriate technique.

Kuntz61 described an inconstant intrathoracic branch that interconnects the first and second thoracic nerves, involving sympathetic fibers that reach the branches of the brachial plexus without passing through the cervicothoracic ganglion, main source of postganglionic fibers for the upper limb. Recently, Chung et al.62 have studied the anatomic variations of Kuntz nerve in dead patients and found it on both sides in 48.1% and only on one side in 68.2% of the cases. Based on these findings, they recommend cutting the parietal pleura over the costal arch longitudinally for at least 1.5 cm laterally to the sympathetic trunk to make sure the nerve has been sectioned. Our preference for sympathectomy and not only for sympathicotomy is based on the fact that by removing or coagulating the sympathetic trunk, we eliminate the possibility of regeneration or maintenance of a functional Kuntz nerve. This nerve might have only anatomic importance, not interfering in surgical success, which indicates the necessity of redefining its role in sympathectomy.63

Our conclusion is that video-assisted thoracoscopic cervicothoracic sympathectomy is a simple, effective and safe procedure, in addition to an unquestionable technical advance in the treatment of hyperhidrosis and selected cases of severe ischemia of the hand, causalgia and long QT syndrome.

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