21 de Fevereiro de 2020 - 23:53
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Hyperhidrosis - Excessive perspiration

Compensatory or reflex perspiration happens in a different region after the sympathectomy was done (craniofacial, palmar, axillar and/or plantar). It is observed mainly on thorax, between mammillas, anterior and posterior thoracic walls, superior abdomen, and on the back. It may occur on legs, thighs, groin and feet also. This is without any doubt, the most commented side effect of THORACIC SYMPATHECTOMY. When it is small or moderate patients tolerate it, but when it is severe, patients report, “they are worst than before surgery”.

Compensatory perspiration may appear in precocious postoperative, few months later, or even (and less frequent) years after surgery. According to our observation, the intensity of compensatory perspiration is stabilized after six months.

In a patient submitted to a thoracic sympathectomy there is a reduction of the effective area of perspiration, which is responsible for the maintenance of thermal control. So if a patient has a smaller area to lose heat through sweat, it is logical to suppose that an increase of sweating on the remaining skin will happen.

Although, this concept is not accepted by the majority of authors and it has suffered modifications the last three years. To be truly a compensatory perspiration the sweat that was not eliminated by hands, axilla or feet after sympathectomy should be lost in another part of the body. But observation shows that some sympathectomized patients sweat more abundantly in areas not affected by sympathectomy. Sweating is more abundant than before surgery. For LIN this perspiration is a reflex perspiration.

Its prevalence varies. Literature reports prevalence between 54 to 70% in a discreet or moderate form, bearable, having its intensity reduced in six months. Because of the excellent results related to associated craniofacial, palmar, axillar and plantar hyperhidrosis, patients may tolerate it quite well. But 1 to 4% of patients present it in a severe form, which is considered unbearable. Even if its prevalence is small, this complication cannot be foreseen and it is considered a serious problem when it appears in a severe form.

The compensatory perspiration is related to room temperature, humidity, physical activity etc. It is less tolerated in humid and warm climates. Furthermore, a patient may quantify its intensity in a very inconstant way in a period of few days.

When diagnosing it is important to consider – local temperature and humidity, irritability, working conditions and the psychological structure of patient, his/her expectation concerning the surgery and most importantly, if before the procedure all doubts were clarified and if emphasis was given to the impossibility to foresee the intensity of this side effect.
The first attempt was obviously to associate the severity of compensatory perspiration with the sympathectomy extension. With all accumulated experiences added to the works of Lesech, Riet and Lin there is a current concept, even though not unanimous, that T2 would maintain the majority of afferent stimulus to the sudomotor center at the hypothalamus, therefore, THE PERSPIRATION WOULD NOT BE COMPENSATORY BUT REFLEX. The indication for sympathectomy at T3 level would be indicated for facial and palmar hyperhidrosis, implying the acceptance of lower rates of therapeutic success. Sympathectomy at T3-T4 level would be indicated for axillar hyperhidrosis isolated or associated to palmar hyperhidrosis. Compensatory perspiration is related to the level and not to the number of resected or coagulated ganglions.
There is no way to control it completely when it takes a large extension of body surface. Some authors have used botulin toxin as a therapeutic option when the affected area is well defined.

Several authors reported the use of anticholinergic drugs, especially oxybutynin chloride. Their experiment revealed that this drug could really help when patients are able to tolerate its side effects. For many patients the reduction of reflex sweat produced by its use, eases the discomfort in warm days. Psychological and psychiatric treatment can be very helpful for support and minimization of symptoms.
The reversion of surgery by the interposition of a sural nerve free graft between the two stumps of resected or parched sympathetic trunk is on study. It involves a transplantation of a small nerve from the leg to the region where the nerve was cut off or parched. Since it is a complex procedure it should be reserved to the severe forms of compensatory hyperhidrosis.

Such procedure has been performed for few surgeons and the rate of success is not well known. Dr. Teleranta and Dr. Reinsfeld have personally reported cases of surgeries, but not published yet and the results are not very encouraging.

Dr. Lin recommends clipping instead of resection of sympathetic trunks. The advantage of this technique is that if a severe compensatory perspiration happens, the clips can be removed. From five patients who had the clips removed three got better in two months, one in six months and another had no improvement. It is easier to remove a clip than to make nerve transplantation.

Table 1 compares the prevalence of Compensatory/ Reflex Hyperhidrosis in the world literature. Our rates were included there also.

In our series 77,7% of patients have Compensatory/Reflex Perspiration in an acceptable and tolerable way, but 47% of them presented a severe form.

The graph 1 analyses its the prevalence and localization.
It is facial, neck or sternal superior region perspiration after eating or smelling food. People may report this kind of perspiration after eating seasoned foods.
Seldom facial dryness requires the use of hydrating lotions. Patients who had acne prior to surgery may have this problem solved weeks after the surgery.
Hands may become very dry after surgery and the use of hydrating cream may be necessary. The frequency of use depends on each individual. The great majority of patients do not report such discomfort.
In this kind of surgery thoracic pain of small or medium intensity is expected. It is caused by an inflammation of pleura (pleuritis) resulting of surgery or a reaction of intercostal nerve that is located under the ribs (intercostal neuralgia), therefore, in the intercostal space used for the introduction and manipulation of the optical and instruments. The use of analgesic and non-hormonal anti-inflammatory drugs relieve patients most of the time. Eventually, the pain may be severe and caused by an intercostal neuritis requiring the administration of strong painkillers, sedatives and steroids. Occasionally, postoperative costal pain in the intercostal space is caused by the compression of intercostal nerve in the space utilized for the optical and instruments.
Some carriers of hyperhidrosis feel it before it actually happens (or not), the sweating of hands, face, axilla or feet. This feeling “I am going to sweat”, is like a “premonitory aura”. This sensation “I’m going to sweat” and does not sweat it is called phantasm sweat and some patients feel it after sympathectomy.
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