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Endoscopic Thoracic Sympathectomy. Abbas E. Abbas , MD Chief of Thoracic Surgery, Ochsner Clinic Medical Center New Orleans, USA aabbas@ochsner.org. Curso Cirugía Mínimamente Invasivo en Tórax 12,13 y 14 de Noviembre del 2010. Indications. Palmar and axillary hyperhydrosis

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Endoscopic Thoracic Sympathectomy


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    1. Endoscopic Thoracic Sympathectomy Abbas E. Abbas, MD Chief of Thoracic Surgery, Ochsner Clinic Medical Center New Orleans, USA aabbas@ochsner.org Curso Cirugía Mínimamente Invasivo en Tórax 12,13 y 14 de Noviembre del 2010

    2. Indications • Palmarand axillaryhyperhydrosis • Facial flushing • Upper extremity ischemia • Chronic regional pain syndrome

    3. Hyperhydrosis • Palmar, axillary, and plantar hyperhydrosis • Excessive sweating of the palms of the hands, axillae, and soles of the feet • Creates vocational, social, and medical impairments

    4. Vocational Writing Keyboard Driving Clothing Social Hand shaking Sales Marketing Hand holding Clothing selection Clothing changes Clinical Impact of Hyperhydrosis • Medical • Rashes • Fungal infections

    5. Hyperhydrosis • Primary (idiopathic) • Secondary

    6. Hyperhydrosis • Primary • Over-stimulation of sympathetic nervous system • Most common form • Unknown etiology • Localized • Palms • Axilla • Soles of feet • Scalp, face

    7. Hyperhydrosis • Secondary • Hyperthyroidism, hypertension • Diabetes / pheochromocytoma • Menopause • Obesity • Drug use • Anti-depressants • Anti-emetics

    8. Treatment of Primary Hyperhydrosis • Anti-perspirants • Iontophoresis • Botox • Systemic medications • Surgery • Axillary liposuction • Excision of axillary tissue • Sympathectomy

    9. Treatment of Secondary Hyperhydrosis • Treatment of the underlying condition

    10. Medical Treatments • Anti-persirants • Aluminum chloride (Drysol) • Glutaraldehyde, tannic acid, astringent

    11. Medical Treatments • Iontophoresis / Drionics • Second line treatment • Palmar and plantar • Electric current (15 – 30 mA) • Immersion 20 minutes 2 – 3 times / week • 70% effective in mild Hyperhydrosis • Sweating returns after cessation of treatment

    12. Medical Treatments • Anticholinergics • Robinul 1 – 4 mg po TID • Dry mouth, urinary retention, constipation, dizziness • Oxybutynin (Ditropan) 10 – 20 mg po daily • Dry mouth, dizziness • Rebound excessive sweating

    13. Medical Treatments • Alpha agonists • Clonidine (Catapres) 0.1 to 0.3 daily • Dry mouth, dizziness, sleepiness, fatigue • Less effect over time • Rebound sweating • Beta blockers • Inderal 10 mg potid or prn

    14. Medical treatments • Botox • Chemical denervation of sweat glands • 50 – 500 units injection • Hands and axillae • Repeat every 2 – 6 months • Pain, hand weakness 1 – 2 weeks, dry mouth, bladder paralysis, bowel inactivity • Effective in 70 – 80% of axillae • Effective in 25 – 40% of palms

    15. Upper Extremity Ischemia • Raynaud’s disease • Berger’s disease • Small vessel atherosclerosis

    16. Chronic Regional Pain Syndrome • CRPS, also known as Reflex Sympathetic Dystrophy • Chronic severe pain due to prior injury • Etiology unknown

    17. Chronic Regional Pain Syndrome • Findings • Cool, mottled upper extremity • Extremely sensitive to light touch • Claw hand • Some of the pain is mediated by Sympathetic Nerve Fibers • Results • 20 – 50 % reduction in narcotic usage

    18. Surgical Sympathectomy • Cervical • Injury to neurovascular bundle • Trans-axillary • Poor exposure • Thoracotomy • Pain and expense • Posterior • Pain, exposure • VATS • Outpatient, low pain, good exposure

    19. Sympathetic levels (web-like) • T1 • Scalp and face • Neck • Hands 10% • T2 • Hands 90% • Face 10% • T3 • Hands 90% • Axilla 90% • T4 • Axilla 90% • Chest 50%

    20. Patient Selection • Must fail conservative therapy • Topical agents • Iontophoresis • Oral medication • Botox • Must rule out secondary cause • Usually very general sweating

    21. Patient education • Compensatory sweating • 4 to 40% • Truncal and groin • Treatment options • Sympathectomy procedure • Support group

    22. VATS Sympathectomy technique • Supine position, sitting up, arms out • Single lumen endotracheal tube • CO2 insufflation • Two 5 mm incisions • 5 mm endoscope • Long cautery, harmonic scalpel, or clips

    23. Surgical Technique • 5 mm Incisions posterior to Pectoralis • 5 mm port, CO2 insufflation, 15 cm H20 • 5 mm port, 5 mm Endoscope • 3 mm cautery • T2 Dan Miller, MD Emory • T3, T4 Mayfield and Houck, Reisler • Carry laterally 2 – 3 cm, Kuntz nerves. • Evacuate CO2 completely

    24. Post-op • Immediate extubation • PACU CXR • Small pneumothorax common • Instructions regarding chest pain and shortness of breath • Home with Hydrocodone/APAP

    25. Single Level T2 Sympathectomy • 50 patients (41 female) • T2 and accessory nerves only • Single-lumen endotracheal tube • CO2 insufflation • Single bilateral access incisions (4 mm) • 3-mm, 30-degree thoracoscope, • Electrocautery nerve division, and no chest drainage. • Median operating time was 22 minutes (14 – 35) • 100% outpatient • Pain at 3 months 1% • Outcomes • 98% no sweating (1 pt required reop for T3) • 12% compensatory sweating Miller, D et al. Ann ThoracSurg 2007;83:1850 –3

    26. Sympathectomy Level And Compensatory Hyperhidrosis After Sympathectomy • 282 with palmarhyperhidrosis • 179 patients (64%): division at T2 level only • 103at levels T2, T3, and T4 • Operative time 19 min (14 – 30) • Hospital stay 0 – 1 days • 1% inpatient – pain • Results • 99% no sweating • 0% Horner’s Syndrome • 0% gustatory sweating • Compensatory hyperhidrosis • 23 pts in T2 group (13%) • 35 pts in T2 - T4 group (34%; P = .011) Miller, D et al. J ThoracCardiovascSurg 2009;138:581-585

    27. Temporary Thoracoscopic Sympathetic Block for Hyperhidrosis • 25 patients concerned about CH were scheduled for VATS block first • 2.5 cc marcaine 0.25% block at T2-T3 and accessory nerves • 100% no sweating in target areas with duration 2 – 10 days • 12% (3 pts) compensatory sweating (2 mild, 1 severe) • One patient declined further sympathectomy due to CH • At VATS sympathectomy • 100% no sweating • 5% compensatory sweating • All pts satisfied Miller, D et al. Annals of Thoracic Surgery 2008,  85 (4), pp. 1211-1216

    28. Summary • Hyperhydrosis, CRPS, ischemia • Medical treatment first • Aluminum chloride • PO medications • Botox • Iontophoresis • Surgery • Axillary fat pad resection • VATS Sympathectomy

    29. With special thanks to: • Dr. William Mayfield: WellStar Thoracic Surgery, Marietta, GA • For his support with much of the material presented