Hyperhidrosis is a disorder characterized by excessive sweating that occurs in up to 3% of the population. The excessive sweating can occur in the hands (palmar hyperhidrosis), in the armpits (axillary hyperhidrosis), or in the feet (plantar hyperhidrosis). Although nobody understands the exact cause of this excessive sweating, it is known that the sweating is controlled by the sympathetic nervous system.
Patients with hyperhidrosis have excessive sweating that hampers their activities of daily living. It is sometimes brought on by stress, emotion, or exercise, but can also occur spontaneously. Patients with palmar hyperhidrosis have wet, moist hands that sometimes interfere with grasping objects. Most patients with palmar hyperhidrosis also consider it a difficult social problem since they have the potential to leave the other person's palm very moist, a sensation most people find unpleasant. Those who suffer from axillary hyperhidrosis sweat profusely from their underarms causing them to stain their clothes. Once again, this proves to be very unsightly and a social disadvantage. Plantar hyperhidrosis is the excessive sweating of the feet and leads to moist socks and shoes as well as increased foot odor.
The initial treatment for hyperhidrosis is usually medical and does not involve surgery. There are topical agents and antiperspirants available (i.e., Drysol) that are astringents that tend to dry up the sweat glands. These products typically lead to the undesirable side effect of excessively dry skin. Another treatment is iontophoresis, which involves electrical stimulation, usually to the hands or feet. Patients place their hands or feet in a bath through which an electrical current is passed. This treatment tends to "stun" the sweat glands and can decrease the secretion of sweat for periods of 6 hours to one week. Many find this treatment to be time-consuming and painful. One of the more recent treatment options is the injection of botulinum toxin (Botox) into the area of excessive sweating. This is a toxin that affects nerve endings and decreases the transmission of the nerve impulses to the sweat glands thus resulting in decreased sweating. It generally requires several injections in the palms or underarms and it remains effective from one to six months. Repeated injections are required to maintain an adequate level of dryness and noncompliance tends to occur due to the painful injections.
Historically, surgery has been reserved for those patients in whom the less invasive medical treatments have failed to provide adequate treatment. With the newer and less invasive surgical methods, definitive surgical correction is being considered much earlier. The surgical treatment of hyperhidrosis involves destroying or removing a specific portion of the main sympathetic nerve. The sympathetic nerve "chain" is formed by a plexus of nerves located next to the ribs in the chest. The spine is made up of vertebrae, which are blocks of bone stacked one on top of another like building blocks. The branches that form this sympathetic "chain" come from between these building blocks and end in a bundle of cells called a ganglion. There is a ganglion at each vertebral level of the spine and all these ganglions are attached one to another longitudinally to form the "sympathetic chain.
In order to treat palmar (hand) hyperhidrosis, the second thoracic ganglion is interrupted. Many surgeons will also remove the third ganglion to maximize the chance of completely preventing sweating of the hands. In order to treat the armpit, the second and third ganglia are targeted.
In the past, this often required a moderate to large sized incision in the chest, which required cutting muscles and separating ribs to expose the sympathetic chain. However, recent advances in technology have produced less invasive methods, such as the so-called endoscopic thoracic sympathectomy (ETS), also known as thoracoscopic sympathectomy. Under general anesthesia, one or two 5 millimeter incisions are made below the armpit. Through these incisions, a camera and instrument are placed to allow the surgeon to interrupt the targeted ganglions as dictated by the patient's symptoms. After one side is completed, the surgeon then turns his/her attention to the opposite side and an identical procedure is performed. The entire procedure typically lasts less than one hour.
There are certain risks that are common to all forms of surgery, such as bleeding, infection and the risks of general anesthesia. The incidence of any of the above potential complications is very low (1% or less) but such problems can arise with any form of surgery.
There are some potential side effects specifically related to the procedure, the most common being compensatory sweating. One must remember that sweating is one form of regulating the body's heat. If the operation prevents sweating in the upper chest, back and arms, it is possible that patients will notice a greater amount of sweating elsewhere in their body in order to compensate for the lack of sweating in the upper extremities. This is called "compensatory sweating" and can occur on the face, abdomen, back, buttocks, thighs, or feet. While this appears to be merely a nuisance for most patients, occasionally it can be severe and interfere with the patient's lifestyle. Finally, there is a small incidence of Horner's syndrome (1%) that can occur if the highest sympathetic ganglion (the first ganglion or "stellate" ganglion) is damaged during the procedure. Overall, the incidence of significant complications or side effects remains gratifyingly low and the overwhelming majority of patients report being very satisfied with their results. In fact for most, it is described as a life-changing procedure!
The probability of success varies with the anatomic location of the excessive sweating. ETS will cure at least 95% of excessive hand (palmar) hyperhidrosis and approximately 90% of armpit (axillary) hyperhidrosis. Approximately 75% of patients with hyperhidrosis of the feet (plantar) will note some improvement, however, the operation is not designed to treat this disorder and should not be used primarily if this is the only complaint.
Although ETS is overall a safe and highly effective method of treatment for the hyperhidrosis syndrome, it must be realized that it remains a surgical procedure with the inherent risks described above. As with most disorders, non-invasive medical forms of therapy should be tried prior to surgery. It is only when these prove to be unsuccessful or impractical for long-term use that a surgical procedure should be contemplated. Once the decision to pursue surgery is made, patients would best be served looking for a board certified thoracic surgeon experienced in performing video-assisted thoracic surgery (VATS) otherwise known as thoracoscopy.
For more information on Hyperhidrosis or to see if you are a candidate for endoscopic thoracoscopic sympathectomy, call Dr. Scot Schultz at 239-649-0440 for an appointment. You may also visit Sweathelp.org for more information.
Thursday, September 24, 2009
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I have had the ETS procedure and am definitely offended by this post. You definitely underreport the potential side effects of this damaging and irreversible procedure. The compensatory sweating you refer to not only will affect one's lifestyle, it can and often does require someone to make drastic changes. It's not uncommon for someone to sweat through their clothes, heat intollerance in temperatures exceeding 80 F, and other issues such as extreme fatigue, heart arhythmia, desentized areas of the body to heat and touch, and a whole host of other issues that are not even addressed on this blog. No, this is not a
ReplyDeleteminor procedure, and it should not be advertised as such. Cutting or clamping the sympathetic nerve chain in the thoracic cavity will have far reaching and irreversible side effects that will compromise the body's normal nerve function. This does not only affect sweating as this blog advertises. Do not pursue this procedure or any surgical procedure as an effective cure to control sweating. This is an irresponsible blog, and the author should be reviewed by the AMA for irresponsible advertising.
"Sympathectomy involves dissection of the main sympathetic trunk in the upper thoracic region thus interrupting neural messages that ordinarily would travel to many different organs, glands and muscles. It involves division of adrenergic, cholinergic and sensory fibers which elaborate adrenergic substances during the process of regulating visceral function."
ReplyDeleteJournal of Applied Sciences Research, 6(6): 659-664, 2010
Sympathectomy is misrepresented by many surgeons, including the author/owner of this blog.
financial interests may unduly influence professionals’ judgments
ReplyDeletewidespread relationships with industry have created significant risks that… financial interests may unduly influence professionals’ judgments.
“conflicts of interest” threaten the integrity of research, the objectivity of education, the quality of patient care, and public trust in medicine.
Conflict of Interest in Medical Research, Education, and Practice
Released:
April 21, 2009
Type:
Consensus Report
Topics:
Biomedical and Health Research, Education
Activity:
Conflict of Interest in Medical Research, Education, and Practice
Board:
Board on Health Sciences Policy
"sympathectomy has been used for many years but the mechanisms by which this works are not absolutely clear"
ReplyDeleteANZ J Surg. 2003 Jan-Feb;73(1-2):14-8.
Cutaneous innervation in man before and after lumbar sympathectomy: evidence for interruption of both sensory and vasomotor nerve fibres.
http://www.ncbi.nlm.nih.gov/pubmed/12534731
We describe a patient who underwent upper thoracic sympathectomy for palmar hyperhidrosis, and whose symptoms subsequently deteriorated, becoming worse than those on initial presentation.
ReplyDeleteRecurrence of hyperhidrosis after endoscopic transthoracic sympathectomy—case report and review of the literature
C.H. ORTEU 1 , J.M. MCGREGOR 1 , J.R. ALMEYDA 1 M.H.A. RUSTIN 1
1 Dermatology Departments, The Royal Free Hospital, Pond Street, London NW3 2QG and The North Middlesex Hospital, London N18 1QX, UK
Copyright 1995 Blackwell Science Ltd
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