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Sympathetic   Ablation   for   Primary   Palmar   Hyperhidrosis
Could controversies be solved?



Moshe Hashmonai, MD,  Technion -Israel Institute of Technology, Faculty of Medicine, Haifa, Israel

Alan EP Cameron, MCh, MA, Nuffield Hospital, Ipswich, UK

Claudio Su�rez Cruzat, MD, Clinical Santa Maria, Santiago, Chile


On behalf of the International Society of Sympathetic Surgery  (ISSS)





Corresponding Author:		Moshe Hashmonai MD, FACS
				PO Box 359,
				Zikhron Ya'akov, 3095202,   Israel
				email:	 HYPERLINK "mailto:hasmonai@inter.net.il" hasmonai@inter.net.il
				Tel.:	+972-4-6293829
				Fax:	+972-4-6293828

A B S T R A C T
 	Excessive perspiration of the palms of unknown etiology is present in a substantial number of the young people.  It may cause severe social, emotional and occupational handicaps.  A multitude of therapies exist, but sympathetic ablation is the only method that may obtain permanent relief.   Sympathectomy, however, is not devoid of consequences; compensatory hyperhidrosis (increase in perspiration in areas of the body unaffected by the sympathetic ablation) is the most important and may attain devastating proportions.   With the advent of thoracoscopic surgery, several modifications of the standard T2-T3 ablation were introduced.  It was postulated that lowering the level of ablation and reducing its extent would reduce the amount of compensatory hyperhidrosis.  Transection, of the sympathetic chain or ganglionic electrocoagulation became popular.  Published data are, however, still controversial.    To resolve the dilemmas, well designed studies are required, in which only one variable is evaluated, the exact level of ablation is marked (and postoperatively confirmed by chest radiograph), the level of ablation is ganglion, not rib, based, and results are quantitatively assessed.  A standard questionnaire for data compilation has been developed by the International Society of Sympathetic Surgery, which is willing to assist and promote such studies. 


















I N T R O D U C T I O N
	 Primary hyperhidrosis is a pathological condition of excessive secretion of the eccrine sweat glands in amounts greater than required for physiological needs (1).   The etiology is unknown but some case are familial (2).   It usually develops in childhood or adolescence.   A rare epidemiological study showed that 0.6-1.0% of  young subjects complained of excessive perspiration of varying severities and anatomical locations, a quarter of whom had severe palmar sweating, resulting in severe social, emotional and occupational handicaps (3).   A multitude of therapies have been proposed for the treatment of primary palmar hyperhidrosis (PPHH), however, the only treatment which may permanently abolish palmar hyperhidrosis is sympathetic ablation (4).  Historically, open upper dorsal sympathectomy for PPHH invariably consisted in excising the second and third thoracic ganglia, the second thoracic ganglion being considered the key for sympathetic innervation of the hand (5).    However, this procedure has consequences.   Compensatory hyperhidrosis (CH), the development of overperspiration in areas of the body unaffected by the sympathetic ablation, is the most frequent one and may be devastating (6, 7).  With the advent of thoracoscopy which greatly simplified the procedure, a plethora of surgical modifications to upper dorsal sympathectomy for PPHH were developed in the search of a method that would reduce the occurrence and degree of CH (8).   These modifications cover (a) the surgical technique (size, number and inlet sites of ports); (b) the level and extent of ablation; (c) the type of ablation (resection, or transection, or thermocoagulation, or clipping of the chain / ganglion / rami communicantes); (d) the desired result of ablation (degree of sweating reduction); (e) the methods by which results are being evaluated.    A multitude of contradictory data has been published, further complicating the picture, thus confusing the reader who is seeking to learn how to treat a patient with PPHH.   In the present study the literature is reviewed in order to clarify the controversies.   Nevertheless, to provide a definitive answer new scientific studies with proper measurements are needed.    

M A T E R I A L   A N D   M E T H O D S
	A search of the literature was performed in MedLine, using the terms  Primary Palmar Hyperhidrosis AND Sympathectomy / Sympathicotomy / Sympathetic Ablation AND Compensatory Hyperhidrosis, for the years 1990-2014 (included).  All relevant articles were examined and additional earlier publications were also retrieved.    The retrieved articles were compiled into three groups, concerning the surgical technique, the level and extent of ablation, and the type of ablation.  The resulting CH was examined, as well as the methods by which its degree was estimated.  

R E S U L T S   A N D   D I S C U S S I O N
THE SURGICAL TECHNIQUE 
	The surgical techniques indirectly impact on the type of surgical ablation.   It is awkward to excise the ganglia using a single working instrument.   This requires superior technical surgical ability, untoward mishaps like damaging a blood vessel are more likely to occur, and it is more time consuming.   In comparison, electrocoagulating a ganglion, transecting the chain by diathermy, or clipping these structures may quickly and easily be performed using even one port.    These advantages are probably one of the reasons that led to the technical modifications. 
THE LEVEL AND EXTENT OF ABLATION
	Originally, resection of the, C8/T1(stellate) and T2 ganglia was thought to be required in order to sympathetically denervate the upper limb (9, 10).    Later, ablation of the T2 ganglion alone was considered sufficient to obtain complete sympathetic denervation of the hand (5, 11).  
Despite these considerations, resection of T3 was often performed in addition to T2 (3). Surgeons then came to believe that lowering the level of ablation would reduce the incidence of CH, and this became applicable when endoscopic techniques were introduced (i.e. approaching the chain from below rather than from above).  
Lowering the Level
 The belief that lowering the level reduced CH may have arisen almost by accident.  In one study the authors twice mistook the level of sympathectomy, but were nevertheless successful in attenuating PPHH while reducing the incidence and severity of CH (12).     Their approach was rapidly adopted by several surgeons.   However, reports continued to be published and a review of the literature for the years 1990-2006, did not confirm this hypothesis (13).   One subsequent article, entitled an "Expert Consensus" reviewed the literature from  1991-2009 and concluded that lowering the level of ablation was appropriate but was based on only ten selected studies out of 102 clinical trials (14).  Furthermore, contradictory reports continued to be published.    Three recent publications have reported reduced CH by lowering the level of ablation (15-17) but  four other studies contradict this conclusion (18-21).
Restricting the Extent (the number of ablated ganglia)
Similarly to the level of resection, limiting the amount remains controversial.   Some studies suggest that ablating more than one ganglion tends toward a higher incidence of CH (22-24).  However a recent study comparing four groups of patients who underwent T2-3, T2-4, T2-5, T2-6 ablations resulted in no statistical difference in the incidence of CH (25).  
Thus the subject remains controversial.  However, a trend may be detected, namely that lowering the level of ablation reduces the resulting CH, but increases residual palmar sweating (26, 27).
THE TYPE OF ABLATION
	In the review published in 2008 (13), no less than 42 different methods of sympathetic ablation were identified, and more have been published later.   It is unfeasible to evaluate each of these methods.   The few comparative studies provide contradictory data.    Excising the sympathetic ganglia achieves the most extensive denervation.  Transecting the chain (sympathicotomy / sympathotomy) or electrocoagulating ganglia apparently preserves some innervation, as proven by physiological studies of cardio-respiratory function (28).   If the degree of CH depends on the degree of denervation, it is logical that lesser denervation will cause less CH.    This has been confirmed in some studies (29, 30).    However, in another study no statistically valid difference was observed (31).    Furthermore, the attempt to reduce CH by less traumatic ablations has a price: a higher rate of recurrence (32).  
EVALUATION OF RESULTS   AND   RECOMMENDATIONS
Design  of  Studies
	Comparative studies should be organised so that only one variable exists between the groups that are compared, and the groups themselves should not contain variables.  So for example in one study  T2-3 sympathectomies (excision of ganglia) were compared to T3-4 sympathicotomies (transection of the sympathetic chain) (33) and in each group there were patients with variable symptoms (palmary and axillary sweating).   So the reader is unable to decide to which variable (the level or the method of ablation) the differences are to be attributed and the different indication    further blurred the results. 
Compilation  of  Data
	When coming to overview the literature, it is often impossible to compile results of studies because data are collected by different questionnaires.  This makes meta-analysis almost   impossible.   To overcome this problem, the International Society of Sympathetic Surgery (ISSS) has developed a standard questionnaire which is appended on the website of the Society ( HYPERLINK "http://www.isss.net" www.isss.net; enter "About ISSS", and then "Recommendations").  
Requirements
To allow comparison, the following data are required:
a.   Precise level of ablation:   To positively identify the level, a metallic clip is placed during surgery and its position confirmed by a postoperative chest radiography.   Mistaken estimations have occurred and published (12, 34).     The reason for these is the common belief that the first rib is not visible during thoracoscopy (35), but in another study the first rib was visible during thoracoscopy in about half of the patients and was palpable in the rest (36).   
b.   Precise anatomical orientation:  The level of ablation is presented in the various publications either by rib count (R), segmental-vertebral level (T for the thoracic chain), or by designing specifically the ganglion (G).   In most studies, the level of ablation is estimated by counting the ribs.  However, it is the ganglia which are the sympathetic supply of the upper limb and their anatomy is variable.   In an anatomical study, 9.1% of T2 ganglia were fused with the stellate ganglion, only 50% were in the second intercostal space, 20% were located over the upper border of the third rib and 6% were found over the third rib (37).  This down ward trend of location increases with the T3 and even more with the T4 ganglia (37).   Therefore, the level of surgery should be documented using anatomical visualization and localization of the ganglia (G), not by rib count (R).
c.   Standardization:   The method of reporting sympathetic ablations has been standardized and is reported in the ISSS web site.   However, additional standardization is still required.  In the past, the standard goal of sympathetic ablation was obtaining dry palms.   With the regression from G2 to lower ablations, residual moisture in the palms is considered by many authors as "acceptable".   It is true that normal palms are not completely dry, but there is no quantitave study to decide what should be considered "normal".   Furthermore, there is no way to estimate what is the exact method of ablation to obtain the "desired" amount of residual palmar moisture.   
QoL  Questionnaires  vs. Metrics
	Results are evaluated in most articles by obtaining patients' satisfaction.  Several Quality of Life (QoL) questionnaires have been developed (38-42).  Patient's satisfaction is no doubt very important.  However, this is a subjective evaluation, depending on several factors like the preoperative degree of oversweating, the occupation of the patient, and the temperature in which the patient is working.   Obviously, patients with more severe sweating pre-operatively will report the highest postoperative improvement by QoL questionnaire (43).   The same degree of residual palmar sweating will affect differently a clerk with office activities compared to one with limited manual activity, or a person working outdoors in a hot humid climate versus one working in air conditioned indoors facilities.    Although important, studies based on patient's satisfaction lack a scientific basis.   An objective test is required to measure pre- and post operative sweating.   Several metric methods and instruments have been developed: skin resistance (conductance) (44), ventilated capsule technique (45), evaporimetry (humidity and temperature) (46), electrical measurements of sweat activity (47), weight loss (for total body amount of perspiration) (48), and sudometry/gravimetry (transepidermal water loss) (49), and have all been advocated.   The use of metrics will allow in future studies to obtain an objective, valuable, and scientifically based instrument in evaluating results.

C O N C L U S I O N S
	Many of the existing controversies are solvable.  To overcome the disagreements, properly designed studies and metric evaluations are required.   In order to solve some of the controversies and promote scientific evaluation, one of the main topics to be discussed in the next International Symposium on Sympathetic Surgery (Santiago de Chile, 15-17 October 2015) will be to examine the assistance that ISSS may offer to future potential investigators in designing studies.   














R E F E R E N C E S
1.	Sato K, Kang WH, Saga K, Sato KT (1989)   Biology of the sweat glands and their disorders II. Disorders of sweat gland function. J Am Acad Dermatol 20:713-726.
2.	Kaufman H, Saadia D, Polin C, Hague S, Sindleton A et al .(2003)   Primary hyperhidrosis. Evidence for autosomal dominant inheritance.  Clin Auton Res13:96-98.
3.	Adar R, Kurtchin A, Zweig A, Mozes M (1977)   Palmar hyperhidrosis and its surgical treatment: a report of 100 cases.  Ann Surg 186:34-41.
4.		Hashmonai M, Kopelman D, Assalia A (2000)   The treatment of primary palmar hyperhidrosis: a review.  Surg Today 30:211-218.
5.	Goetz RH, Marr JAS (1944)   The importance of the second thoracic ganglion for the sympathetic supply of the upper extremities.  Clin Proc 3:102-114.
6.	Ross JP (1933)   Sympathectomy as an experiment in human physiology.  Br J Surg 21:5-19.
7.	Shelley WB, Florence R (1960)   Compensatory hyperhidrosis after sympathectomy.  New Engl J Med 263:1056-1058.
8.	Hashmonai M, Assalia A, Kopelman D (2001)   Thoracoscopic sympathectomy for palmar hyperhidrosis. Ablate or resect.  Surg Endosc 15:435-441.  
9.	Woollard HH, Norrish RE (1933)    The anatomy of the peripheral sympathetic nervous system.  Br J Surg 21:83-103.
10.	Kuntz A, Alexander WF, Furcolo CL (1938)    Complete sympathetic denervation of the upper extremity.   Ann Surg 107:25-31.
11.	Wong CW (1997)   The second thoracic sympathetic ganglion determines palm skin temperature in patients with essential palmar hyperhidrosis.  J Auton Nerv Syst  67:121-4.
12.	Lin CC, Wu HH (2001)   Endoscopic T4-sympathetic block by clamping (ESB4) in treatment of hyperhidrosis palmaris et axillaris � experience of 165 cases.  Ann Chir Gynaecol  90:167-169.   
13.	Kopelman D, Hashmonai M (2008).   The correlation between the method of sympathetic ablation for palmar hyperhidrosis and the occurrence of compensatory hyperhidrosis: a review.   World J Surg 32:2343-2356.  
14.	Cerfolio RJ, Milanez de Campos JR, Bryant AS, Connery CP, Miller DL et al. (2011)   The society of thoracic surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg 91:1642-1648.
15.	Sun GZ, Xu LH, Zhou B (2010)   The choice of thoracoscopic sympathectomy in the treatment of palmar hyperhidrosis among different procedures.   Zhonghua Yi Xue Za Zhi 90:2065-2067.
16.	Kim JB, Park CK, Kum DY (2011)   The effect of thoracoscopic sympathicotomy at the fourth rib (r4) for the treatment of palmar and axillary hyperhidrosis.   Koeran J Thorac Cardiovasc Surg 44:154-158.
17. 	Bryant AS, Cerfolio RJ (2014)   Satisfaction and compensatory hyperhidrosis rates 5 years and longer after video�assisted thoracoscopic sympathotomy for hyperhidrosis.   J Thorac Cardiovasc Surg 147:1160-1163.
18.	Les�che G, Castier Y, Thabut G, Petit M-D, Combes M et al. (2003)   Endoscopic transthoracic sympathectomy for upper limb hyperhidrosis: limited sympathectomy does not reduce postoperative compensatory seating.  J Vasc Surg 37:124-128.
19.	Licht PB, Pilegaard HK (2004)   Severity of compensatory sweating after thoracoscopic sympathectomy.   Ann Thorac Surg 78:427-431.
20.	Baumgartner FJ, Reyes M, Sarkysian GG, Iglesias A, Reyes E (2011)   Thoracoscopic sympathicotomy for disabling palmar hyperhidrosis.   Ann Thorac Surg 92:2015-2019.
21.	Cai S, Huang S, An J, Li Y, Weng Y et al. (2014) Effect of lowering or restricting sympathectomy levels on compensatory sweating.  Clin Auton Res [In Print � Epub 17/4/2014].
22.	Weksler B, Blaine G, Souza ZBB, Gavina R (2009)   Transection of more than one sympathetic chain ganglion for hyperhidrosis increases the severity of compensatory hyperhidrosis and decreases patient satisfaction.   J Surg Res 156;110-115.
23.	Miller DK, Bryant AS, Force SD, Miller JI Jr (2009)   Effect of sympathectomy level on the incidence of compensatory hyperhidrosis after sympathectomy for palmar hyperhidrosis after sympathectomy for palmar hyperhidrosis.   J Thorac Cardiovasc Surg 138:581-585.
24.	Deng B, Tan QY, Jiang TG, Zhao YP, Zhou JH et al. (2011) Optimization of sympathectomy to treat palmar hyperhidrosis: the systematic review and meta-analysis of studies published during the past decade.  Surg Endosc  25:1893-1901.
25.	Gunn TM, Davis DM, Speicher JE, Rossi NP, Parekh KR et al. (2014)   Expanded level of sympathetic chain removal does not increase the incidence or severity of compensatory hyperhidrosis after endoscopic thoracic sympathectomy.  J Thorac Cardiovasc Surg [In Print � Epub 22/7/2014].
26.	Kim WO, Kil HK, Yoon KB, Yoon DM, Lee JS (2010)   Influence of T3 or T4 sympathicotomy for palmar hyperhidrosis.  Am J Surg 199:166-169.
27.		Aoki H, Sakai T, Murata H, Sumikawa K (2014) Extent of sympathectomy affects postoperative compensatory sweating and satisfaction in patients with palmar hyperhidrosis.  J Anesth 28:210-213.
28.	Fiorelli A, D'Aponte A, Canonico R, Palladino A, Vicidomini G et al. (2012)   T2-T3 sympathicotomy versus sympathectomy for essential palmar hyperhidrosis: comparison of effects on cardio-respiratory function.  Eur J Cardiothorac Surg 42:454-461.    
29.	Atkinson JLD, Fealey RD (2003)   Sympathotomy instead of sympathectomy for palmar hyperhidrosis: minimizing postoperative compensatory hyperhidrosis.  Mayo Clin Proc 78:167-172.
30.	Mohhebi HA, Mehrvarz S, Manoochehry S (2012)   Thoracoscopic sympathicotomy vs sympathectomy in primary hyperhidrosis.  Trauma Mon 17:291-5.
31.	Aydemir B, Imamolu O, Okay T, �elik M (2014)   Sympathectomy versus sympathicotomy in palmar hyperhidrosis comparing T3 ablation.   Thorac Cardiovasc Surg [In Print   Epub 1/8/2014].
32.	Assalia A, Bahous H, Ilivitzki A, Assi Z, Hashmonai M et al. (2007)   Thoracoscopic sympathectomy for primary palmar hyperhidrosis: resection versus transection � a prospective trial.   31:19766-1979.
33.	Scogniamillo F, Serventi F, Attene F, Torre C, Paliogiannis P et al. (2011)   T2-T4 sympathectomy versus T3-T4 sympathicotomy for palmar and axillary hyperhidrosis.  Clin Auton Res  21:97-102.
34.	Chou SH, Kao EL, Lin CC, Huang MF (2006)   The outcome of ganglion clipping in hyperhidrosis and blushing.  Clin Auton Res  16:240-242.
35.	Satyapal KS, Singh B, Partar P, Ramsaroop L, Pather N (2003)   Thoracoscopy: A new era for surgical anatomy.  Clin Anat  16:538-541.
36. 	Wong CW (1997)   Transthoracic video endoscopic electrocautery of sympathetic ganglia for hyperhidrosis palmaris: special reference to localization of the first and second rib.  Surg Neurol  47:224-230. 
37.	Chung IH, Oh CS, Koh KS, Kim HJ, Paik HC et al. (2002)   Anatomic variations of the T2 nerve root (including the nerve of Kuntz) and their implications for sympathectomy.   J Thorac Cardiovasc Surg 123:498-501.
38.	Amir M, Arish A, Weinstein Y, Pfeffer M, Levy Y (2000)   Impairment in quality of life among patients seeking surgery for hyperhidrosis (excessive sweating): preliminary results. Isr J Psychiatr Relat Sci 37:25-31.   
39.	de Campos JRM, Kauffman P, de Campos Werebe E, Filho LOA, Kusniek S et al. (2003)   Quality of life, before and after thoracic sympathectomy: report of 378 operated patients.  Ann Thorac Surg 76:886-891.  
40.	Kumagai K, Kawase H, Kawanishi M (2005)   Health-related quality of life after thoracoscopic sympathectomy for palmar hyperhidrosis.   Ann Thorac Surg 80:461-466. 
41.	Panhofer P, Zacherl J, Jakesz R, Bischof G, Neumayer C (2006)   Improved quality of life after sympathetic block for upper limb hyperhidrosis.  Br J Surg 93:582-586.  
42.	Cin� CS, Robertson SGW, Young EJM, Cartier B, Clase CM (2006)   Effect of endoscopic sympathectomy for hyperhidrosis on quality of life using the illness intrusiveness rating scale.  Minerva Chir 61:231-239.  
43.	Koskinen LO, Blomstedt P, Sj�berg RL (2012)   Predicting improvement after surgery for palmar hyperhidrosis.   Acra Neurol Scand  126:324-328.
44.	Edelberg R (1977)   Relation of electrical properties of skin to structure and physiologic state.   J Invest Dermatol  69:324-327.
45.	Lang E, Foerster A, Pfannm�lller D, Handwerker HO (1993)   Quantitative assessment of sudomotor activity by capacitance hygrometry.  Clin Auton Res  3:107-115.
46.	 Elkeeb R, Hui X, Chan H, Tian L, Maibach HI (2010)   Correlation of transepidermal water loss with skin barrier properties in vitro: comparison of three evaporimeters. Skin Res Technol 16:9-15.
47.	Ellaway PH, Kuppuswamy A, Nicotra A, Mathias CJ  (2010)   Sweat production and the sympathetic skin response: improving the clinical assessment of autonomic function. Auton Neurosci  155:109-114.
48.	Kopelman D, Assalia A, Ehrenreich M, Ben-Amnon Y, Bahous H et al. (2000)   The effect of upper dorsal thoracoscopic sympathectomy on the total amount of body perspiration. Surg Today  30:1089-1092.
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