An estimated 1% of the population suffers from palmar hyperhidrosis. This condition, characterized by excessive sweating of the palms, is also frequently associated with excessive perspiration involving the hands, face, and soles of the feet, as well as the armpits, chest or back. Dr. Jeffrey Hagen, Assistant Professor of Cardiothoracic Surgery, notes that "as a consequence of this disorder patients often suffer from embarrassment, social isolation, or difficulty at work." The exact cause of this disorder is not known, but the symptoms are the result of over-activity of the sympathetic nervous system, which normally controls such bodily responses as blushing, sweating, and heat regulation. Treatment options for hyperhidrosis include a variety of lotions, antiperspirants, medications and biofeedback techniques. In some patients, however, these remedies fail. "Surgical procedures in which the sympathetic nerves are divided have been performed for many years" explains Dr. Steve DeMeester, Assistant Professor of Cardiothoracic Surgery. "While successful in the great majority of patients, the procedures required an open incision either on both sides of the neck or chest, and as a consequence many patients were reluctant to undergo the operation. Fortunately, all this has changed."

Revolutionary new treatment

A minimally invasive surgical technique has been developed which cures palmar hyperhidrosis. The procedure, called Thoracoscopic Sympathectomy, or Endoscopic Transthoracic Sympathectomy (ETS), allows the sympathetic nerves to be divided with very low risk, short recovery time, and minimal pain. Using a video telescopic camera and a single small incision on each side, the surgeon can identify and divide the sympathetic nerve chain that is responsible for the excessive sweating. Dr. Hagen notes that "the benefits of the procedure are immediate, and in most cases, the patient can return home on the day of surgery." "Furthermore", Dr. Hagen added, "because the procedure is so minimally invasive both sides can usually be done the same day, thereby eliminating the hassle of two separate operations."

Surgeons at the University of Southern California Division of Thoracic/Foregut Surgery have successfully applied this technique for the past five years. Specializing in Thoracic Surgery (chest surgery), they have extensive experience all aspects of thoracoscopic surgery. "While all operative procedures have some degree of risk" points out Dr. DeMeester, "when performed by an experienced thoracic surgeon a thoracoscopic sympathectomy is quite safe, and has minimal side effects." "Successful elimination of the sweating" according to Dr. DeMeester "can be achieved in more than 95 percent of patients with palmar hyperhidrosis". "And what's really great is that the patients wake up from the operation and immediately notice that their hands are dry". The procedure is also effective in the majority of patients with excessive sweating involving the feet, and in about 50% of those with excessive sweating in the armpits. The operation is not considered cosmetic or elective, and is covered by nearly all major insurance plans.

If you are interested in more information regarding this exciting new treatment option for hyperhidrosis, we recommend that you discuss it with your family physician. To learn more, contact the Division of Thoracic/Foregut Surgery at the University of Southern California by fax at (323) 865-0119, or by e-mail at HyperhidrosisInstitute@surgery.usc.edu.

Background

The sympathetic nervous system is one of the two major components of the nervous system. It is responsible for maintaining normal balance (homeostasis) in many of the body's systems. In addition to being the major regulator of body temperature, it also controls production of sweat by glands throughout the body. Regulatory centers in the brain send out nerve impulses which traverse the spinal cord and go to nerve fibers in the chest and upper abdomen. Here they end in small nodules of nerve tissue called ganglia. These ganglia are arranged in a line along each side of the spine, where they form the sympathetic trunk. Fibers from the sympathetic trunks then pass into peripheral nerves and travel throughout the body. It has long been known that interruption of these nerve fibers could be used to cure some disorders of the circulation and hyperhidrosis.

However, until recently surgical division of the sympathetic nerves to the upper extremities required an open surgical procedure either through an incision in the neck or the chest. When performed through the chest the operation required a rather sizable incision with separation or spreading of the ribs. Patients would typically be hospitalized for up to a week and required a tube for drainage of the chest. The pain could last weeks to months, and simultaneous operations on both sides (bilateral procedures) were not feasible. While shown to be highly effective, the risks and prolonged recovery time limited the use of this technique to only the most severely affected individuals.

Currently, minimally invasive thoracoscopic techniques allow the performance of a wide variety of procedures traditionally performed through an open incision. One procedure, the Thoracoscopic Sympathectomy, has been applied for the past decade in Europe with excellent results. This procedure has been shown to be effective in the treatment of palmar (hand), plantar (foot), and axillary (trunk) hyperhidrosis, as well as a variety of other conditions such as chronic abdominal pain and Reflex Sympathetic Dystrophy (RSD). Thoracoscopic sympathectomy is indicated for the treatment of severe, incapacitating sweating of the upper and lower extremities, when medical treatment has failed. It is also the most effective treatment for facial blushing, which can cause great social and professional difficulties.

Symptoms

Common symptoms of hyperhidrosis include excessive, uncontrollable sweating of the hands, armpits, groin and feet. The symptoms are often so severe that the affected individual may literally drip with perspiration, creating problems in social situations and in some cases, making work impossible. Other disorders such as hyperthyroidism need to be excluded. This can generally be accomplished by a simple blood test.

Technique

The operative procedure involves the use of a general anesthetic. A small incision is made just behind the armpit crease, first on one side and then the other. The incision, less than an inch in size, is well hidden and nearly invisible in most cases. Through the incision an operating telescope attached to a video camera is inserted. The lung is allowed to deflate and the sympathetic chain is identified along the chest wall near the spine. Instruments are passed through the operating telescope, and with the advantage of a highly magnified view precise division of the sympathetic trunk is performed. For patients with palmar hyperhidrosis the sympathetic trunk is divided at the level of the 2nd ganglion. This limited sympathectomy minimizes the incidence of compensatory sweating. Treating facial hyperhidrosis or blushing requires division of the trunk up to the base of the 1st rib, which must be done with care to avoid injury to the Stellate ganglion. For patients with prominent symptoms of axillary sweating, the sympathectomy is continued down to the third or fourth ganglion level. The lung is then re-expanded, generally without the need for a chest drainage tube, and long acting local anesthetic is administered to minimize postoperative discomfort. The procedure is usually done in the outpatient setting, and the patient can return to work in a matter of days. Furthermore, a bilateral procedure (both sides) can safely be performed during the same anesthetic.

Results

Patients can be monitored during the operation to insure that division of the nerve trunk has been successful. In almost all cases the benefits of the operation are immediate and dramatic. More than 95% of patients with palmar hyperhidrosis awaken from the anesthetic with warm dry hands. Further, for most patients the benefits are long lasting. Success rates for facial blushing and sweating are about 90%, but success rates for plantar and axillary sweating are less predictable. Improvement can be expected in 50 and 75% of patients respectively.

Complications

In general, complications are very rare, and they are usually of minor importance.

• Bleeding: The risk of serious bleeding with this operation is well under one percent. Blood transfusion is almost never required.

• Infection: As with any surgical procedure, infection is a possibility. The risk of infection associated with this procedure is less than 1 percent.

• Pneumothorax: Either incomplete removal of the air introduced into the chest during the procedure or a minor injury to the lung can cause a collection of air in the chest cavity called a pneumothorax. In most cases this can be managed with simple observation, as it will gradually be absorbed. In rare instances, a drainage tube will be required temporarily to assist in re-expansion of the lung.

• Treatment failure: In patients with severe disease in the chest cavity (pleural space), it may not be possible to expose the sympathetic trunk and perform the procedure with a thoracoscopic technique. Rarely, despite division of the sympathetic trunk some sweating in the upper extremity persists.

• Horner's syndrome: The most feared complication of a sympathectomy is the occurrence of a Horner's syndrome. Caused by injury to the 1st ganglion (Stellate ganglion), the symptoms of Horner's syndrome include unilateral (one-sided) dryness of the face, asymmetry of the pupil of the eye, and drooping of the eyelid. In experienced hands, this complication occurs in less than one half of one percent of patients, but can be quite disfiguring when it does occur. It is a particular risk when the sympathetic trunk is deliberately divided high, just below the Stellate ganglion, to treat cases of facial hyperhidrosis.

Side-effects

Up to one half of patients will notice increased sweating (compensatory sweating) in other areas of the body after a thoracoscopic sympathectomy. The frequency of this side effect seems to depend on the extent of the sympathectomy performed. Compensatory sweating occurs most commonly on the trunk or thighs, and is usually associated with exercise or stress. Most patients view this as a minor inconvenience when compared to the effect palmar or facial sweating had on their lives. However, approximately one percent of patients are significantly troubled by their compensatory sweating.

Gustatory sweating, or increased sweating when eating or smelling certain foods occurs in about 30% of patients. Rarely considered a major problem, the sweating is most often triggered by strong or spicy foods.

Contraindications

Contraindications to thoracoscopic sympathectomy include untreated hyperthyroidism, severe pleural disease (TB or empyema), and significant cardiac or pulmonary disease which would increase the risk of a general anesthetic.

For more information

To learn more, contact the Division of Thoracic/Foregut Surgery at the University of Southern California by fax at (323) 865-0119, or e-mail at HyperhidrosisInstitute@surgery.usc.edu.