HYPERHIDROSIS

Hyperhidrosis is the pathological increase of sweating in any part of the body. It can affect the palms of hands, soles of feet, armpits, face, and so on. The area where hyperhydrosis is bothersome is most frequently the palms of hands (palmar hyperhidrosis).

Palmar hyperhidrosis
Facial hyperhidrosis
Palmar hyperhidrosis
Facial hyperhidrosis
Axillary hyperhidrosis
Plantar hyperhidrosis
Axillary hyperhidrosis
Plantar hyperhidrosis
Botox for the treatment of hyperhidrosis
Initially, medical traeatment with ointments, lotions and the application of electric currents will be used. If this proves inefficient, botulinum toxin will be injected. It can be injected in the doctor’s office; however, the downside is that it only lasts for a while, its effect decrease after each injection, and it is both expensive and painful. For those cases where medical treatments do not suffice, surgical treatment may be offered.

TREATMENT OPTIONS

Initially, medical treatment with ointments, lotions and the application of electric currents will be used. If this proves inefficient, botulinum toxin will be injected. It can be injected in the doctor’s office; however, it only lasts for a while, its effect decreases after each injection, and it is both expensive and painful. For those cases where medical treatments do not suffice, surgical treatment may be offered.

Patients who suffer hyperhydrosis know from own experience that conservative treatments don’t usually have permanent results and, in many occasions, are no efficient at all. In these cases, surgical treatment may be considered.

The objective of the upper thoracic endoscopic sympathectomy (UTES) is to destroy those sympathetic ganglia that control sweat production in hands and armpits.  Once the ganglia are destroyed, sweat production in the hands and even in the armpits is reduced significantly.

WHAT DOES UTES CONSIST OF?

Operating room distribution in upper thoracic endoscopic sympathectomy

The upper thoracic sympathectomy, although originally described in 1927, has evolved grealtly in the way in which it is performed owing to the improvements in knowledge and equipment. Today it is performed with endoscopic equipment, thus reducing the surgical aggressivity of the procedure and making easier the treatment in otherwise healthy patients.

There are different ways to destroy or eliminate the sympathetic ganglia responsible for excessive sweating. In our clinic we use endoscopy through a single 6mm incision in the thorax (in the armpit, one incision on each side to be operated). We then introduce a video-endoscope which allows us to see the ganglia and destroy them with electrocautery, laser, or clips.

HOW IS UTES PERFORMED?

Sketch of the endoscopic system used in UTES
Intraoperative picture with endoscopy system in place
Sketch of the endoscopic system used in UTES
Intraoperative picture with endoscopy system in place

Under general anaesthesia, a thin endoscope (tube), 6mm in diameter and connected to a video camera, is introduced through a small incision in the armpit. To avoid any lesions, the lung of the side which is being operated on is collapsed by using a special endotracheal tube. This tube allows us to selectively ventilate one lung or the other one depending on what is required.

Sketch upper thoracic sympathetic chain
The endoscope is driven towards the 2nd and 3rd ribs, in the posterior side of the thoracic cavity. Once the ganglia are localised and their position confirmed, they are destroyed with laser or electrocautery or with clips. Finally, the endoscope is removed and the lung is re-expanded. Occasionally a thin draining tube through the initial incision will be left.
Endoscopic i dentification of the endoscopic sympathetic chain
Rx confirmation of the rib level
Endoscopic identification of the sympathetic chain
Rx confirmation of the rib level
Endoscopic destruction of the sympathetic chain
Single skin incision after the procedure
Endoscopic destruction of the sympathetic chain
Single skin incision after the procedure

After a ten to fifteen minutes the procedure is repeated on the other side.

POST-OPERATIVE RECOVERY

Endoscopic sympathectomy
Six hours after surgery the patient can start eating and sit on the bed. The patient will be told to do respiratory exercises, breathing deep, to favour adequate lung expansion. Usually the patient will be discharged the next day.

If any chest drains are present, the patient will be able to stand up 24 hours after the procedure and their discharge will be postponed till 24 hours after the removal of the chest drain.

The wounds are closed with inside surgical stitches, so not only are they not seen but also they do not need to be removed.

Scar of endoscopic approach with a single entrance

WHAT ARE THE POSSIBLE COMPLICATIONS?

Intra-operative complications are very rare, the most important being the accumulation of blood or air in the pleural cavity. The initial treatment in this case would be holding the chest drain for some more days.

WHAT ARE THE RESULTS?

The results are immediately seen after the intervention, with total dryness of the hands and approximately 80% dryness in armpits. When excessive sweating is not completely corrected, it is usually due to some fibres remaining undestroyed, owing probably to an unusual anatomy of the sympathetic chain. The surgical procedure can be repeated to correct it, but this is, however, exceptional

Recurrences are possible but extremely rare.

Palmar hyperhidrosis before treatment
Palmar hyperhidrosis after endoscopic sympathectomy
Before the operation
After the operation

The most frequent secondary effect is an increase in sweating in other parts of the body (chest, back, buddocks, thighs); however, it can be reduced by controlling the extension of the sympathectomy or by doing a supraselective sympathectomy. In this procedure, rami-communicans are targeted, instead of ganglia or the sympathetic chain. It is a much more selective procedure but it is also more techically demanding and has higher risks, so it is only performed on special cases where the risk of compensatory hyperhidrosis is high.

However, a very common beneficial secondary effect is a moderate reduction in the sweating of feet.

In selected cases, the procedure can be carried out through RF (radiofrequency) percutaneously, i.e. with needles. The procedure is carried out on an outpatient basis and under local anaesthesia and sedation. Its results are initially good but, though not as much as before, frequently the sweating will return after some time. This is because the sympathetic chain has not been destroyed, only blocked through a burn produced by RF, so, over time, the sympathetic nerves will grow again and the sweating will return. This procedure is performed in hands and face when an endoscopic sympathectomy implies some special risk or danger, such as for Jehovah Witnesses, which do not accept the hypothetical possibility of a blood transfusion. However, this procedure is most effective in plantar hyperhydrosis (hyperhydrosis of the feet), where results do not need to be as perfect as in hands and where a small amount of sweating is less of a problem. In addition, lumbar endoscopic sympathectomy is technically much more complex, and lumbar percutaneous sympathectomy can be used, too, in patients with vascular problems in the lower limbs (diabetes, vascular pathology…) as well as in cases of neuropathic pain.

Percutaneous radiofrequency thoracic sympathectomy
Percutaneous radiofrequency thoracic sympathectomy
Percutaneous radiofrequency thoracic sympathectomy
Percutaneous radiofrequency thoracic sympathectomy
Percutaneous radiofrequency lumbar Simpatatectomía
Percutaneous radiofrequency lumbar simpatatectomy
Percutaneous radiofrequency lumbar simpatatectomy
Percutaneous radiofrequency lumbar simpatatectomy
Pre-operative situation in percutaneous lumbar sympathectomy
Post-operative situation in percutaneous lumbar sympathectomy
Preoperative situation in percutaneous lumbar sympathectomy
Postoperative situation in percutaneous lumbar sympathectomy

TO SUMMARISE

Upper thoracic endoscopic sympathectomy (UTES) is a simple and highly effective technique in the treatment of hyperhidrosis.

Our technique, with a single incision on either side, makes it even less aggressive, more tolerable, and aesthetically better.

Percutaneous RF sympathectomy is possible, but its results are not as good as those of the endoscopic sympathectomy.

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