Background/aim: The goal of this retrospective study was to evaluate the outcomes and complications of bilateral videothoracoscopic
sympathicotomy without using single-lung ventilation in the treatment of primary hyperhidrosis and facial blushing.
Materials and methods: We retrospectively reviewed 154 consecutive patients (70 females and 84 males) who underwent bilateral
sympathicotomy for palmar, axillary, and facial/scalp hyperhidrosis or facial blushing from February 2005 to June 2013. The patients
were intubated with single-lumen endotracheal tube, and then sympathicotomies were performed via videothoracoscopy during
controlled apnea periods.
Results: Sympathicotomies were performed at costal levels 2, 3, and 4. No perioperative mortality or conversion to open surgery was
recorded. Mean operation time was 31.2 ± 2.4 min and mean hospital stay was 1.1 ± 0.6 days. One patient experienced a unilateral
pneumothorax that required treatment. There were no abnormal hemodynamic parameters measured during the perioperative apnea
periods. The long term follow-up period was 21.4 ± 5 months. Twenty-nine cases (18.8%) were complicated by compensatory sweating.
No recurrence was observed during the follow-up period.
Conclusion: Video-assisted thoracoscopic sympathicotomy without lung isolation provides effective cure of primary hyperhidrosis and
facial blushing. This procedure can shorten the operative time without any aberrant hemodynamic shifts

Ekmekçi, Perihan

Han, Serdar

Kaplan, Tevfik

Koçer, Bülent

TURKISH JOURNAL OF MEDICAL SCIENCES

English

Ufuk Universitesi Akademik Acikerisim Sistemi

771http://journals.tubitak.gov.tr/medical/Turkish Journal of Medical Sciences Turk J Med Sci(2015) 45: 771-774© TÜBİTAKdoi:10.3906/sag-1405-51Bilateral sympathicotomy for hyperhidrosis without using single-lung ventilationTevfik KAPLAN1,*, Perihan EKMEKÇİ2, Bülent KOÇER3, Serdar HAN11Department of Thoracic Surgery, Faculty of Medicine, Ufuk University, Ankara, Turkey2Department of Anesthesiology and Reanimation, Faculty of Medicine, Ufuk University, Ankara, Turkey3Department of Thoracic Surgery, Ankara Numune Teaching and Research Hospital, Ankara, Turkey* Correspondence: tevfikkaplan@yahoo.com1. IntroductionPrimary hyperhidrosis is an idiopathic disorder characterized by excessive sweating. Its prevalence rate in the general population ranges from 0.3% to 4.5%. Video-assisted thoracoscopic sympathectomies have been successfully performed for many years in the treatment of this condition (1). The operation can be done as sympathicotomy, where the sympathetic chain is transected, or as sympathectomy, where the chain and ganglia are resected or ablated (2).Video-assisted thoracoscopic surgery (VATS) is usually performed under general anesthesia with double-lumen endotracheal tube intubation (3). The undesired complications of double-lumen intubation are airway injury, decrease in oxygen saturation, increase in airway pressure, poor lung ventilation, and displacement of the tube during the operation (4). There are several studies indicating the use of single-lumen endotracheal tubes in VATS with CO2 insufflations in the hemithorax (5).  In this retrospective study we evaluate the efficacy, safety, and long-term results of videothoracoscopic sympathicotomy without lung isolation utilizing single-lumen endotracheal tube intubation.  2. Materials and methodsOne hundred and fifty-four patients, 70 (45.5%) females and 84 (54.5%) males, who underwent one-stage bilateral thoracoscopic sympathicotomy to treat palmar, axillary, or facial/scalp primary hyperhidrosis or facial blushing, were retrospectively analyzed from February 2005 to June 2013 (Table 1). The mean age was 24.8 ± 5.6 (18–36) years.2.1. OperationPatients were intubated by a single-lumen tube and placed in the supine position with the arm abducted to 90°. The back was elevated to 40°. At first, patients were hyperventilated with 100% O2, and when the O2 saturation of the hemoglobin was 100%, the apnea period was initiated. During the apnea period we inserted two ports into the chest cavity, one located at the axillary region Background/aim: The goal of this retrospective study was to evaluate the outcomes and complications of bilateral videothoracoscopic sympathicotomy without using single-lung ventilation in the treatment of primary hyperhidrosis and facial blushing.   Materials and methods: We retrospectively reviewed 154 consecutive patients (70 females and 84 males) who underwent bilateral sympathicotomy for palmar, axillary, and facial/scalp hyperhidrosis or facial blushing from February 2005 to June 2013. The patients were intubated with single-lumen endotracheal tube, and then sympathicotomies were performed via videothoracoscopy during controlled apnea periods.   Results: Sympathicotomies were performed at costal levels 2, 3, and 4. No perioperative mortality or conversion to open surgery was recorded. Mean operation time was 31.2 ± 2.4 min and mean hospital stay was 1.1 ± 0.6 days. One patient experienced a unilateral pneumothorax that required treatment. There were no abnormal hemodynamic parameters measured during the perioperative apnea periods. The long term follow-up period was 21.4 ± 5 months. Twenty-nine cases (18.8%) were complicated by compensatory sweating. No recurrence was observed during the follow-up period. Conclusion: Video-assisted thoracoscopic sympathicotomy without lung isolation provides effective cure of primary hyperhidrosis and facial blushing. This procedure can shorten the operative time without any aberrant hemodynamic shifts. Key words: Hyperhidrosis, sympathicotomy, complications Received: 15.05.2014              Accepted/Published Online: 09.10.2014              Printed: 30.07.2015Research Article772KAPLAN et al. / Turk J Med Sciand the other at the midclavicular line between the third (R3) or fourth (R4) ribs. Gravity and controlled apnea were used to descend the lung from the apex to perform the sympathicotomy, because there are no pressurized gas insufflations with this technique. The part of the sympathetic chain overlying the rib was transected by electrocautery on a high costal level, sparing the sympathetic ganglia. A sympathicotomy was performed at the second costal (R2) level for facial/scalp hyperhidrosis or facial blushing. An R3 sympathicotomy was performed for isolated palmar hyperhidrosis and an R3–R4 sympathicotomy for axillary hyperhidrosis. In all cases the transection was extended to 2 cm laterally over the rib to transect accessory nerve fibers. The O2 saturation of the hemoglobin was allowed to drop to 90%, and then the patients were ventilated again. The right side was approached first. When the procedure was completed, a temporary small feeding tube was inserted into the chest during closure of the soft tissue and was removed before the skin closure. A postoperative chest X-ray was performed to exclude pulmonary and pleural abnormalities.  The data, including characteristics of patients; surgical procedures; operating time; hemodynamic parameters such as blood O2 saturation, end-tidal CO2 levels, and arterial blood pressure measured during the intraoperative apnea periods; and postoperative complications and recurrence were all analyzed. 3. ResultsA total of 308 video-assisted thoracoscopic sympathicotomies were performed on 154 patients by the same surgical team. No conversion to open surgery was necessary and there were no aberrant hemodynamic shifts during the procedure. None of the patients experienced Horner’s syndrome, intercostal neuralgia, or hemothorax, neither postoperatively nor in the long-term follow-up after this procedure. However, one patient experienced a pneumothorax that required treatment by a chest tube. There was no operation-related mortality. Hyperhidrosis was observed in the palmar and axillary region in 45 (29.2%) patients and only in the palmar region in 67 (43.5%) patients. Furthermore, facial blushing or hyperhidrosis was observed in 42 (27.2%) patients.  One-stage bilateral video-assisted thoracoscopic sympathicotomy was performed for all patients. R2 sympathicotomy was performed for 42 patients for facial hyperhidrosis or blushing, and R3 transection was performed for 67 patients for palmar hyperhidrosis only. R3–R4 sympathicotomy was performed for 45 patients for axillary and palmar hyperhidrosis.  The mean operation time from intubation to extubation was 31.2 ± 2.4 min, whereas the mean time from skin incision on one side to skin closure on the contralateral side was 17.8 ± 1.6 min. Mean hospital stay was 1.1 ± 0.6 days. The hemodynamic parameters measured during the perioperative apnea periods were as follows: mean oxygen saturation measured by pulse oximetry was 95.6 ± 4.5%, end tidal carbon dioxide was 38.7 ± 6.7 mmHg, and mean systolic and diastolic arterial blood pressure was 120.4 ± 10.4/75.9 ± 8.8 mmHg (Table 2). In the palmar hyperhidrosis group all patients had dry hands immediately after the surgery and during their hospitalization. In the palmar and axillary hyperhidrosis group we observed dry hands in all patients but in 3 patients axillary hyperhidrosis had decreased after the Table 1. Patient characteristics.    Mean age 24.8 ± 5.6 years n (%) Sex Male  70 (45.4) Female 84 (54.5) Localization of Palmar and axillary (R3–R4 transected) 45 (29.2) hyperhidrosis Isolated palmar (R3 transected) 67 (43.5) Facial blushing or (R2 transected) 42 (27.2)HyperhidrosisComplications Compensatory sweating 29 (18.8) Pneumothorax 1 (0.64)Recurrence 0 (0)Mean operation time 31.2 ± 2.4 min  Mean hospital stay 1.1 ± 0.6 days  773KAPLAN et al. / Turk J Med Scisurgery, but was not completely resolved. Furthermore, 2 patients with facial hyperhidrosis complained of still having hyperhidrosis around their upper lip area after the surgery (Table 3). No patients experienced a recurrence of hyperhidrosis during the follow-up period.All patients were advised preoperatively that long-term follow-up was necessary, and they were contacted and assessed by follow-up evaluations, telephone interviews, and questionnaires. The follow-up period varied from 6 to 40 months (mean: 21.4 ± 5 months).The evaluation of compensatory hyperhidrosis showed that 8 patients (5.1%) who only had palmar hyperhidrosis, 12 (7.7%) who had palmar and axillary hyperhidrosis, and 9 (5.8%) who had facial/scalp hyperhidrosis or facial blushing developed new mild sweating on the lower back, abdomen, buttocks, and thighs, yet this did not bother them (Table 4). The total compensatory hyperhidrosis rate was 18.8% (29 patients). In 4 patients the compensatory sweating occurred during the first postoperative month. It was seen in 15 patients during the third postoperative month, and in the remaining 10 patients it did not appear until 2 years after the surgery. 4. DiscussionPrimary hyperhidrosis presents most often in adolescents. It is a pathological condition of excess sweating, which is required for thermoregulation, but it can also occur as a psychological response to an unknown etiology. The sweating usually affects the palms or axillae but may also be seen in other areas of the body (6).   Many reports have found that thoracic sympathectomies for palmar hyperhidrosis are efficient, even after long-term follow-ups (7,8). In this study, there was no recurrence after a mean follow-up period of 21.4 months. The effectiveness of sympathicotomy for axillary hyperhidrosis is slightly lower than for palmar hyperhidrosis and it varies between 86% and 93% (9). In this study, the effectiveness of sympathicotomy for axillary hyperhidrosis was 93.3%. It was 100% for the isolated palmar group and 95.2% for the facial blushing or hyperhidrosis group.     Compensatory sweating appears to be a relatively common side effect after these procedures, with an occurrence rate between 60% and 90% having been reported in some series (10,11). Several studies described fewer side effects of sympathicotomy (7,12). Our rate was 19.7%. We think this low compensatory hyperhidrosis rate occurred because we only transected the sympathetic chain and did not remove or injure the ganglia of the chain or the axons from the spinal cord neurons innervating the ganglia. Therefore, we think that this approach decreases the synaptic reorganization at the sympathetic chain level, which may cause a reduction in compensatory hyperhidrosis.Several undesired complications of endobronchial intubation with double-lumen endotracheal tube have been reported in the literature (13,14). In a major study, the rate of complications of endobronchial intubation were reported as follows: decreased O2 saturation of hemoglobin 9%, increased airway pressure 9%, poor lung isolation 7%, air trapping 2%, and airway injury 0.4% (4). During video-assisted thoracoscopic sympathicotomy, different techniques are used for intraoperative ventilation. Double-lumen endotracheal tube is the most common ventilation method, but there are some reports stating that the use of laryngeal masks or surgery under sedation with spontaneous ventilation provided satisfactory results (15). In this study, we performed video-assisted thoracoscopic Table 2. Perioperative hemodynamic data.Mean SpO2   95.6 ± 4.5%Mean end-tidal CO2 38.7 ± 6.7 mmHgMean arterial blood pressure           120.4 ± 10.4/75.9 ± 8.8 mmHgTable 3. Effectiveness of sympathicotomy.Percentage (n)Palmar and axillary 93.3% (42)hyperhidrosisIsolated palmar 100% (67)hyperhidrosisFacial blushing or 95.2% (40)hyperhidrosis  Total 96.7% (149)Table 4. Compensatory sweating rates.n (%)Palmar and axillary 12 (7.7) hyperhidrosisIsolated palmar 8 (5.1) hyperhidrosisFacial blushing or 9 (5.8)  hyperhidrosisTotal   29 (18.8)  774KAPLAN et al. / Turk J Med Scisympathicotomy during the controlled apnea periods by utilizing single-lumen endotracheal tubes, and there were no aberrant hemodynamic shifts perioperatively. Moreover, our results were effective, with a low rate of complications. In some reports, mean operation times for bilateral sympathectomies vary from 30 to 91 min (16,17). In this study, the mean operation time from intubation to extubation was 31.2 ± 2.4 min, whereas the mean time from skin incision on one side to skin closure on the contralateral side was 17.8 ± 1.6 min. This was considerably shorter than in other studies in the literature, and it is because of only transecting the sympathetic chain and shortening the duration of the anesthesia procedure. In conclusion, bilateral videothoracoscopic sympathicotomy or sympathectomy is currently a standard surgical technique to treat primary hyperhidrosis. Our results are promising and suggest that videothoracoscopic sympathicotomy without lung isolation utilizing single-lumen endotracheal tube intubation is a valid and safe treatment for primary hyperhidrosis. This procedure can shorten the operation time with a low complication rate compared to other large series of patients in which different techniques were used. References1.  Montessi J, De Almedia EP, Vieria JP, Abreu MM, De Souza RLP, Montessi OVD. Video-assisted thoracic sympathectomy in the treatment of primary hyperhidrosis: a retrospective study of 521 cases comparing different levels of ablation. J Bras Pneumol 2007; 33: 248–254.2.  Pilegaard HK. Thoracoscopic sympathectomy. J Clin Anal Med 2010; 1: 63–65.3.  Cox P, Tobias JD. Noninvasive monitoring of PaCO2 during one-lung ventilation and minimal access surgery in adults: end-tidal versus transcutaneous techniques. J Min Access Surg 2007; 3: 8–13.4.  Hurford WE, Alfille PH. A quality improvement study of the placement and complications of double-lumen endobronchial tubes. J Cardiothorac Vasc An 1993; 7: 517–520.5.  Sancheti MS, Dewan BP, Pickens A, Fernandez FG, Miller DL, Force SD. Thoracoscopy without lung isolation utilizing single lumen endotracheal tube intubation and carbon dioxide insufflation. Ann Thorac Surg 2013; 96: 439–444.6.  Byrne J, Walsh TN, Hederman WP. Endoscopic transthoracic electrocautery of the sympathetic chain for palmar and axillary hyperhidrosis. Brit J Surg 1990; 77: 1040–1049.7.  Rex LO, Drott C, Claes G, Göthberg G, Dalman P. The Borås experience of endoscopic thoracic sympathicotomy for palmar, axillary, facial hyperhidrosis and facial blushing. Eur J Surg 1998; 580: 23–26. 8.  Lewis DR, Irvine CD, Smith FC, Lamont PM, Baird RN. Sympathetic skin response and patient satisfaction on long-term follow-up after thoracoscopic sympathectomy for hyperhidrosis. Eur J Vasc Endovasc 1998; 15: 239–243.9.  Mohebbi HA, Mehrvarz S, Manoochehry S. Thoracoscopic sympathicotomy vs sympathectomy in primary hyperhidrosis. Trauma Mon 2012; 17: 291–295.10.  Dumont P, Denoyer A, Robin P. Long-term results of thoracoscopic sympathectomy for hyperhidrosis. Ann Thorac Surg 2004; 78: 1801–1807. 11.  Zacherl J, Huber ER, Imhof M, Plas EG, Herbst F, Függer R. Long term results of 630 thoracoscopic sympathicotomies for primary hyperhidrosis: the Vienna experience. Eur J Surg 1998; 580: 43–46.12.  Atkinson JL, Fealey RD. Sympathotomy instead of sympathectomy for palmar hyperhidrosis: minimizing postoperative compensatory hyperhidrosis. Mayo Clin Proc 2003; 78: 167–172. 13.  Knoll H, Ziegeler S, Schreiber JU, Buchinger H, Bialas P, Semyonov K, Graeter T, Mencke T. Airway injuries after one-lung ventilation: a comparison between double lumen tube and endobronchial blocker: a randomized, prospective, controlled trial. Anesthesiology 2006; 105: 471–477. 14.  Lee KH, Lim HK, Lee KM, Kim SY. The incidence of sore throat and hoarseness after double lumen endobronchial tube intubation. Korean J Anesthesiol 1998; 35: 484–487.15.  Hsieh YJ, Chen CM, Lin HY, Young TF. Experience of anesthesia during transthoracic endoscopic sympathectomy for palmar hyperhidrosis: comparison between double-lumen endobronchial tube ventilation and laryngeal mask ventilation. Acta Anaesthesiol Sin 1994; 32: 13–20 (in Japanese with abstract in English).16.   Chen YB, Ye W, Yang WT, Shi L, Guo XF, Xu ZH, Qian YY. Uniportal versus biportal video-assisted thoracoscopic sympathectomy for palmar hyperhidrosis. Chin Med J 2009; 122: 1525–1528. 17.  Bouma W, Klinkenberg TJ, Mariani MA. 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Bilateral sympathicotomy for hyperhidrosis without using single-lung ventilation

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Bilateral sympathicotomy for hyperhidrosis without using single-lung ventilation

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