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HYPERHIDROSIS / CONCEPTS - SYMPTOMS
Hyperhidrosis - Excessive perspiration


GENERAL CONCEPTS
Hyperhidrosis could be generalized and it is normally related to physical exercises and emotional factors. Obesity, hyperthyroidism, menopause, psychiatric diseases, tuberculosis, feochromocitoma (?), acromegaly and lymphoma could cause secondary hyperhidrosis.

The hyperhidrosis that cause more concern are the localized or regional ones: (primary hyperhidrosis), palmar, axillar, plantar, and craniofacial. They may occur associated or separately and their intensity may cause discomfort or a change in psychosocial behavior of the individual.

Hyperhidrosis is a dysfunction in the Sympathetic Nervous System resulting in an excessive perspiration at the affected region. Emotional factors are involved and this sweating which is normally intermittent and linked to an excitement reaction, anguish, anxiety, fear or stimulating drugs like caffeine, present in tea, coffee and sodas “cola” type. Hyperactivity of the Sympathetic Nervous System causes hyperhidrosis. During Summer time its intensity is a little more exacerbated. Stress, high temperatures and eating are considered triggers, being the stress the greater one. As proof of such statement, is the fact that while a person is asleep hyperhidrosis seldom occurs. It may happen at any time, any place – in an air-conditioned room, high temperature environment, while eating, reading, watching TV, or without any stress or anxiety.

About 20% of affected people are born with such dysfunction. This fact and the presence of hyperhidrosis in members of the same family may indicate that in some cases a hereditary factor is present. There is no racial distinction, but the incidence is discretely increased among Jewish and Asians and it seems to have a family predominance. It occurs in 0,5 to 1% of the population.
 
SYMPTOMS/ LIMITATIONS
25% of people present palmar hyperhidrosis isolated or associated to plantar at birth, although the majority refers the observance of excess of sweating around 5 years of age, when school activities start. Carriers of Axillar hyperhidrosis report its onset at puberty. Craniofacial hyperhidrosis shows up in adult life and it is exacerbated at mid–life. It may start or be exacerbated in women close to menopause with no relationship to the amount of hormones produced.

Individuals with palmar hyperhidrosis have their social activities, working activities and relationships limited by this dysfunction. They do not feel comfortable to shake hands, and often avoid such contact. School children have difficulty to perform activities using paper. They spot their work, stick to them; handling paper is quite impossible. Adult cannot sign checks and have to wear gloves (even during warm seasons) or carry a hand towel with them constantly. Several patients reported a difficulty to start dating or even to touch other person during moments of intimacy.

Hyperhidrosis may be a hindrance for some professions – pianists, plastic artists, typist, massotherapists, beauticians (make-up), medical doctors, physiotherapists, etc. One of our patients, a dentist, reported a great limitation she had to perform routine tasks in her patients because the required use of rubber gloves provoked an accumulation of sweat inside the glove. Another patient said she was so irritated because she wet the stirring wheel she left the car on the street. Simple gestures like holding hands become impossible for this people.

Axillar hyperhidrosis becomes very unpleasant because of sweat dripping all over the body and the permanent sensation of lack of hygiene, especially if accompanied by foul-smell. Big wet spots are formed in the region and adjacencies causing this people to wear only white or black clothes. We had a picturesque case of a patient whose major desire was to wear a blue shirt. Women dream about wearing colorful clothes especially during Summer time. One of our patients took five baths a day because of the anguish sensation and insecurity concerning her own hygiene. She was worried about what people would think of her. Some people put absorbent pads under the armpits to minimize the effects of perspiration on their clothes.

Plantar hyperhidrosis especially limits patients who have to wear shoes with cotton socks all time. Sandals make them slip. They become irritated with the unpleasant odor of wet leather or plastic, even worse when associated with bromhidrosis. Some patients who try to wear sandals report the mixture of sweat and dust form mud under their feet.

Axillar and/or plantar hyperhidrosis may contribute for or aggravate diseases like bacterial infections, mycosis and contact dermatitis.

Craniofacial hyperhidrosis is less common. In our study 13,6% of patients presented it isolated or associated to another type of hyperhidrosis. Especially the face gets wet when the level of stress or anxiety rises, for instance, in public appearances. Executives, teachers, media professionals and lawyers are particularly limited in their professional activity because they need towels to dry themselves often.

The following table and graph show the hyperhidrosis location in 467 patients submitted to surgery
 
THORACIC SYMPATHECIN TOMY BY VIDEOTHORACOSCOPY
IN THE TREATMENT OF HYPERHIDROSIS

LOCATION
 
THORACIC SYMPATHECIN TOMY BY VIDEOTHORACOSCOPY
IN THE TREATMENT OF HYPERHIDROSIS
LOCATION
 
HYPERHIDROSIS / TREATMENT
Hyperhidrosis - Excessive perspiration


CLINICAL TREATMENT
Frequently the doctor, DERMATOLOGIST, sometimes NEUROLOGIST or ENDOCRINOLOGIST, prescribes tranquilizers, sedatives or antidepressants depending on the evaluation about the influence psychological factors may have on the disease.

Anticholinergic drugs like propantheline and oxifencyclimine (?) are prescribed by oral intake, but side effects are frequent and results are unsatisfactory and limited. Local treatment with anhidrotic drugs such aluminium chloride, formaldehyde and derived have been used without desired results.

Patients come for a consultation after trying several creams, deodorants, etc. Homeopathic, orthomolecular, acupuncture and other alternative treatments are ineffective. Psychological and psychotherapic treatments may help but are palliative, so they should be used as a support.
 
OTHER TREATMENTS
IONTOPHORESIS is the introduction of ions by electric instruments. The treatment requires one application a day for 30 days. A long treatment and the results are temporary and unsatisfactory.

BOTOX (BOTULIN TOXIN) applications have a consecrated use in several situations in esthetic medicine, otorhinolaryngology, etc. In treating hyperhidrosis, its benefits, according to our observation, are partial, unsatisfactory and temporary. The application on the hands is painful and the benefits last 5 to 6 months. The best results are attained in axillar hyperhidrosis, being this, its main indication, especially in recent onsets. It permits patients to postpone surgery or avoid it.

SKIN WITH SWEAT GLANDS RESECTION is done in axillar hyperhidrosis, has a limited indication because the possibility of cicatricial skin retraction on the axillar area diminishes the shoulder and arm mobility. The results are unsatisfactory and recurrences are frequent.

LIPOASPIRATION in axillar area has its limitations because the sweat glands are located above the fat layer and are not removed in this procedure. Recently, the use of aspiratory curettage of the axillar region has been reported.
 
HYPERHIDROSIS / DEFINITIVE SURGICAL TREATMENT
Hyperhidrosis - Excessive perspiration


VIDEOTHORACOSCOPY THORACIC SYMPATHECTOMY
Definitive treatment is already known since 1940 (KOTZAREFF), the cervical thoracic Sympathectomy is done through the resection of the sympathetic ganglions of thoracic trunk.

This method was not well divulged in Brazil because it was done through a large thoracotomy (a big incision on the thoracic wall) or cervical incision, and later, through a minor axillar thoracotomy, but still large and with a limited surgical field.

European authors, especially Scandinavian, using Thoracoscopy presented large series with excellent results since 1950. Dr. Kux, an Austrian surgeon was the great divulger of Thoracoscopy Thoracic Sympathectomy.

Later, the VIDEOTHORACOSCOPY arrived (Thoracic surgery done through video cameras). This surgical method utilizes a micro camera, which increases 20 times the surgical field and small incisions. So the complication and pain during the postoperative time is diminished, so is the time at hospital and the medical-hospital costs. There was a great divulgation of VIDEOTHORACOSCOPY Thoracic Sympathectomy for the treatment of Hyperhidrosis Palmar, Axillar, Craniofacial, Raynaud Disease, Reflex Sympathetic Dystrophy, Causalgia, Vascular Insufficiency of Superior Members, Long QT Syndrome, Facial blushing, Social phobia, and untreatable Angina Pectoris.
 
Sistema Nervoso Simpático Torácico e Cervical
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SURGERY INDICATION
A dermatologist, neurologist, endocrinologist and other professionals involved in diagnosing and/or treating Hyperhidrosis should evaluate patients and referred them to surgical treatment.

Our patients’ age varied from 9-64 years old and the majority of them was operated between 15-25 years old Even though they can be operated in any age, nowadays we advise them to have the surgery for Palmar Hyperhidrosis around 10 years old, so we will prevent the anguish and constraining problems during teenage years. The great majority of our patients were females (67%).
 
CONTRAINDICATIONS
Patients with pulmonary insufficiency, severe cardiovascular insufficiency and uncontrolled diabetes should not be operated. Contraindication is relative for patients with thoracic surgery sequel, thoracic trauma and pleural diseases.

Obese patients should not be operated or operated with restriction because of the difficulty in locating the Sympathetic trunk. Some can have their symptoms softened simply by loosing weight.
 
PRINCIPLES OF THORACIC SYMPATHECTOMY
Since the first publications about cervical thoracic sympathectomy in the treatment of hyperhidrosis there has been progress and a discussion about the level of the thoracic trunk and the number of thoracic ganglions to be removed. The majority of studies were published in the last ten years and their goals were the attainment of better results and more recently, the decrease of side effects such as the compensatory perspiration.

In brief – the sympathetic thoracic ganglion (T1) is the major responsible for sweating and heat loss of face, hands and in minor extension of armpits. T1 in conjunction with C8 (eighth cervical ganglion) form the Stellate Ganglion, which is responsible for the eyelid and pupillary response (orbital area). They should be preserved because an injury may cause Claude Bernard Horner Syndrome. In over 600 operated patients we never had such complication. The second thoracic ganglion (T2) controls the sweat response of hands and face (except the intra-orbital portion), scalp, shoulders and the anterior and posterior parts of the thorax above the mammilla and facial blushing. The third ganglion (T3) affects the sweating of hands, armpits, shoulders and the anterior and posterior parts of thorax above the mammilla and of face in a minor degree. The fourth ganglion (T4) innervates hands and armpits. As you should have noticed there is a sympathetic innervation superposition for hands, face and axillas.
Currently we perform a T2 Sympathectomy for craniofacial hyperhidrosis and for facial blushing, T3 for hyperhidrosis palmar, T3 and T4 for axillar hyperhidrosis associated or not to hyperhidrosis palmar. Literature reveals a tendency, although not unanimous, of clipping instead of sectioning or coagulating the ganglions of the sympathetic trunk, especially after the reports of Lin and Telaranta. This clipping is done at the same levels already mentioned with the advantage that the clips could be removed in case of a severe compensatory hyperhidrosis (more details in the compensatory perspiration section).
 
SURGICAL TECHNIQUE
The surgery is performed under general anesthesia using double lumen tube (Carlens’ tube) for intubation to allow the ventilation of each lung separately and to promote lung collapse in the side to be operated. The patient is in dorsal decumbent position with the trunk elevated 450. A 5mm incision is done in the fourth intercostal space in the medial axillar line. This position is adapted according to the form, dimension, breast position, and the previous presence of silicone implant prosthesis (which does not impede nor hamper the surgery). A second trocar or portal is introduced through the 5mm incision at the third intercostals space. Adjustments are made through direct vision by compressing the thoracic wall at the intercostal space so it stays at “thoracic portion of axilla” and a place for the introduction of the instruments can be chosen. The thoracic trunk can be seen at a sub-pleural position and at the junction of the head of ribs with the vertebra bodies. The first rib and its head over which the stellate ganglion is located cannot be seen. The second rib is the first one to be seen inside the thorax and it serves as a reparation point. By gentle palpation ribs and their respective ganglions can be identified (figure). With a cautery the pleura is opened. Dissection or coagulation of ganglions is performed, isolating the communicating sympathetic ramifications anterior and posterior so that there is no transmission of heat or energy to the intercostal nerves. Sympathectomy at T2 is done in case of craniofacial hyperhidrosis, at T3 for palmar hyperhidrosis, at T3 andT4 for axillar hyperhidrosis associated or not to palmar hyperhidrosis. Currently we opt to perform the clipping done at the same levels. When clipping T2, a clip is placed at the sympathetic trunk over the second rib and another at the sympathetic trunk over the third rib. If clipping T3, a clip is placed at the sympathetic trunk over the third and fourth ribs. For clipping of T3 and T4 a clip should be placed at the sympathetic trunk over the third, the fourth and the fifth ribs. After the end of sympathetic electrocoagulation / section or clipping a thin thoracic drain with a subaqueous external extremity is introduced through the trocar. The pulmonary expansion proceeds under direct vision and the optical is removed. The anesthesiologist keeps on performing pulmonary insufflation maneuvers in the operated side until no more air escapes through the thoracic drain, what means that a complete pulmonary re-expansion has happened. Then the thoracic drain can be removed. Seldom the need to keep the thoracic drain after the surgery happens. Surgery in both sides is done on the same anesthetic action, taking about 40 minutes. The subcutaneous tissue is stitched with monocryl 000 strand and the skin is hastened by surgical adhesive.

VIDEO DOWNLOAD
 
EXAMPLE
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HYPERHIDROSIS SURGERY POSTOPERATIVE
The patient stays at the Recovery Room until his/her complete recovery from anesthesia. Afterwards he/she will be taken to a hospital room where, according to his/her needs, analgesic medication will be administered. He/she will be able to eat in the afternoon after the surgery. Usually the patient is dismissed in the next day. We recommend three days of relative rest and after these he/she may go back to regular activities. Intense physical activities should be avoided for about 15 days.
 
HYPERHIDROSIS / RESULTS
Hyperhidrosis - Excessive perspiration


VIDEOTHORACOSCOPY THORACIC SYMPATHECTOMY RESULTS
The patient already leaves the surgery room with dry face, palms and/or axillas. The results were classified in: EXCELLENT (completely dry region); GOOD (discreet perspiration), FAIR (partial improvement of perspiration) and POOR (no improvement). The following table shows results of several authors, including ours.

Medical literature shows that 94-100% of palmar and /or axillar hyperhidrosis are permanently healed.

Concerning Hyperhidrosis Palmar 99,5% and Craniofacial 90,9%, we attained excellent and good results. For
Hyperhidrosis Axillar 90,7%, the results were good and excellent.
 
TREATMENT OF HYPERHIDROSIS THROUGH VIDEOTHORACOSCOPY
THORACIC SYMPATHECTOMY RESULTS
 
THERAPEUTHIC SUCCESS IN THE TREATMENT OF HYPERHIDROSIS THROUGH
VIDEOTHORACOSCOPY THORACIC SYMPAT
2 Years Follow-Up
 
Graph 1
2 Years Follow-Up
 
Graph 2
 
Graph 3
 
Graph 4
 
Graph 5
 
REMARK
Some authors explain that Axillar Hyperhidrosis lower percentages of therapeutic success (90,7%) are due to the fact that axillar region has 90% of eccrine sweat glands and 10% apocrine sweat glands. The eccrine are sympathetic dependent, so when the sympathectomy is done they stop secreting sweat. The apocrine are not sympathetic stimulated, so they are not influenced by sympathectomy.

Small incisions and a proper treatment of surgical incisions – intradermal sutures – help to obtain an excellent esthetical result.
 
HYPERHIDROSIS / COLLATERAL EFFECTS
Hyperhidrosis - Excessive perspiration


COMPENSATORY OR REFLEX HYPERHIROSIS
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.
 
CAUSE
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.
 
COMPENSATORY /REFLEX HYPERHIDROSIS
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.
 
TREATMENT OF REFLEX / COMPENSATORY PERSPIRATION
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.
 
TABLE 1
 
GRAPH 1
 
GUSTATORY OR OLFACTORY SWEATING
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.
 
FACIAL DRYNESS
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.
 
DRY HANDS
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.
 
THORACIC PAIN
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.
 
PHANTASM SWEATING
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.
 
HYPERHIDROSIS / COMPLICATIONS
Hyperhidrosis - Excessive perspiration


POSSIBLE COMPLICATIONS OF VIDEOTHORACOSCOPY THORACIC SYMPATHECTOMY
Complications related to this procedure have sporadically been described but their prevalence had been inferior to 1%. This rate is inferior when compared to the conventional surgery and surgeries performed by videothoracoscopy to treat other diseases.
 
HORNER SYMDROME (0-1,2%)
Claude-Bernard-Horner Syndrome (miosis, space between upper and lower eyelids diminished, enophthalmia) is caused by direct lesion of the stellate ganglion (eight cervical sympathetic ganglion plus first sympathetic ganglion) or by the transmission of heat and electricity to it when using an electric cautery. This syndrome can be definitive when the star ganglion is resected or coagulated and temporary when is caused by local inflammatory reaction.

Claude Bernard Horner Syndrome was more prevalent previous to videothoracoscopy era specially when it was performed through the supraclavicular region (neck). The rate of this syndrome varies from 1 to 1,2% but with the utilization of videothoracoscopy authors report a rate close to 0%. We did not have such complication in about 1200 surgeries performed in approximately 600 patients.
 
BRACHIAL PLEXUS LESION
The brachial plexus is a group of nerve roots that descend from the neck to the shoulder and superior limb. A lesion may cause muscular weakness, formication and paralysis. In this kind of surgery the plexus is not injured because it is not part of the surgical field, but these symptoms are produced by the stretching of the plexus because of the position –half-seated on surgery table with elevated arms. It may occur paresis of superior limb (0-0,4%) or paresthesia of superior limb (0-0,4%).
 
COMPLICATIONS AND ITS PREVALENCES IN MEDICAL WORLD LITERATURE
Chylothorax (presence of lymph in the pleural cavity) 0-0,8%;
hemothorax (collection of blood in the pleural cavity) 0-0,8%;
pnemothorax needing drainage (collection of air in the pleural cavity) 0,4-1%;
infection of surgical wound (0-1,25%);
pleura hemorrhage (0-0,8%);
atelectasis (0-0,5%);
surgical emphysema (0-2,5%);
pulmonary embolism (0-0,08%);
persistent aerial escape (0-1,25%);
pulmonary lesion (0,0-0,47%);
infection of the pleural cavity /empyema (0%).
 
PLANTAR HYPERHIDROSIS – LUMBAR SYMPATHECTOMY
Patients presenting ISOLATED PLANTAR HYPERHIDROSIS and the ones that were not healed from ASSOCIATED PLANTAR HYPERHIDROSIS may be submitted to LUMBAR SYMPATHECTOMY. It is not clear enough if patients with compensatory perspiration after thoracic sympathectomy for Plantar Hyperhidrosis with no improvement have indication for Lumbar Sympathectomy.
 
GLOBAL RESULTS OF VIDEOTHORACOSCOPY THORACIC SYMPATHECTOMY THERAPEUTIC SUCCESS – 5 YEARS OF SATISFAC
The results are evaluated in relation to “stop sweating” and not necessarily correspond to satisfaction with surgery. The therapeutic success rates (STOP SWEATING) were of 90.9% for craniofacial hyperhidrosis, 99,5% for axillar hyperhidrosis and 32% for associated plantar hyperhidrosis. The satisfaction rates varied from 94-97% when globally considered.

For a better evaluation of results after the Thoracic Sympathectomy for the treatment of Hyperhidrosis, a pre and postoperative quality of life questionnaire (social, personal, emotional, etc.) may be used. Quality of life improvement after the surgical treatment of hyperhidrosis varies between 80 and 86,4%.

The table bellow analyzes the degree of satisfaction.
 
TABLE 1
 
CONCLUSION
The excellent result achieved with VIDEOTHORACOSCOPY THORACIC SYMPATHECTOMY is the responsible for the joy, satisfaction and euphoria presented by patients who carried PALMAR, AXILLAR, CRANIFACIAL and ASSOCIATED PLANTAR HYPERHIDROSIS. There was a change in their behaviour affecting positively their personal and working relationships. That is why it is indicated to all suffers of Hyperhidrosis (palmar, axillar, craniofacial and associated plantar) who want to be free from the discomfort and limitations caused by this disease.
 
HYPERHIDROSIS / FAQ
Hyperhidrosis - Excessive perspiration


Frequently Asked Questions
1. What patients have the indication to be submitted to THORACIC VIDEOTHORACOSCOPY SYMPATHECTOMY?

A. Patients with low and medium degree of hyperhidrosis can be treated in a conservative way, with antiperspiration creams, iontophoresis machines and, in an armpit hyperhidrosis case, with botulinic toxin. All patients that have their social, affective and professional life affected by hyperhidrosis, whether it is by not being able to salute people, in the palmar hyperhidrosis case, by not being able to give interviews because of the “sweat spots” under their armpits, etc., can be submitted to THORACIC SYMPATHECTOMY. IT IS THE PATIENT ITSELF THAT INDICATES THE SURGERY AFTER ANALYZING ALL INFORMATION GIVEN BY THE ASSISTANT DOCTOR.


2. Is it necessary to make an appointment with Dr. Marlos to be operated?

A. Yes, Dr. Marlos exams all patients personally. Although the first contact can be done by e-mail and telephone, in a way to obtain information to know the examinations needed and the surgery date. It is not possible to be submitted to a surgical procedure without a previous appointment with Dr. Marlos.


3. Why doctors, in a general way, do not know and do not provide information about Hyperhidrosis?

A. Medicine has a wide range of activity. It is impossible to be a doctor that has all knowledge about all diseases. There has been a great progress in the last ten years regarding Hyperhidrosis and its treatment, in a special way the THORACIC SYMPATHECTOMY treatment with the release of hundreds of publications related to this subject in the world medical literature. The not expert press has been a model to be followed and of major importance in the broadcasting of knowledge about Hyperhidrosis. Dermatologists, endocrinologists, general physicians, etc… have been obtaining information to orient the treatment as well as to send their patients to an evaluation with a SURGEON WITH VIDEOTHORACOSCOPY OR VIDEO-ASSISTED THORACIC SURGERY HABILITATION.


4. Who isn’t the suitable candidate for a THORACIC SYMPATHECTOMY procedure?

A. Specially patients that claim to “PERSPIRATE THROUGH ALL BODY”. People that have PALMAR, PLANTAR AND ARMPIT HYPERHIDROSIS and perspirate through their thorax, abdomen, groin and legs are not suitable candidates to SYMPATHECTOMY because they develop SEVERE COMPENSATORY HYPERHIDROSIS. Patients with CRANIO-FACIAL HYPERHIDROSIS, therefore patients with indication for SYMPATHECTOMY at level of T2 must be oriented regarding the possibility of SEVERE COMPENSATORY HYPERHIDROSIS in the post-operatory period too.
Patients with generalized hyperhidrosis must be investigated concerning other diseases such as diabetes, tuberculosis, hypoglycemia and hyperthyreodism.
Patients with previous thoracic surgery, inflammatory pleuro-pulmonar diseases, previous thoracic trauma can be submitted to the surgical procedure since properly investigated and elucidated since the pleural adherences may difficult or even forbid the procedure, therefore being relative contraindication.


5. Does any surgeon can perform THORACIC VIDEOTHORACOSCOPY SYMPATHECTOMY?

A.NO. Only surgeons with habilitation in the THORACIC VIDEOTHORACOSCOPY SYMPATHCTOMY and VIDEO-ASSISTED THORACIC SURGERY procedures. DR. MARLOS is TITLE HOLDER IN THORACIC SURGERY of the SOCIEDADE BRASILEIRA DE CIRURGIA TORÁCICA. (Brazilian Thoracic Surgery Society) of which he is TITLE MEMBER and he has an HABILITATION IN VIDEOTHORACOSCOPY CERTIFICATE provided by both COLÉGIO BRASILEIRO DE CIRURGIÕES (Brazilian College of Surgeons) and SOCIEDADE BRASILEIRA DE CIRURGIA TORÁCICA (Brazilian Society of Thoracic Surgery).


6. In what hospitals does DR. MARLOS performs the SYMPATHECTOMY?

A. At the HOSPITAL UNIVERSITÁRIO CAJURÚ and at the SANTA CASA DE MISERICÓRDIA DE CURITIBA, which are institutions of the PONTIFÍCIA UNIVERSIDADE CATÓLICA DO PARANÁ. In both hospitals Dr. Marlos is the headmaster of the Thoracic Surgery service and assistant professor in surgery.


7. Do all patients that submit to a THORACIC SYMPATHECTOMY procedure stop sweating on the spots affected by Hyperhidrosis?

A. In short, they stop sweating on the affected region. 99,5% of the PALMAR HYPERHIDROSIS holders, 90,7% of the ARMPIT HYPERHIDROSIS, 90,9% of the CRANIO-FACIAL HYPERHIDROSIS and 32% of the PLANTAR HYPERHIDROSIS ASSOCIATED.


8. Is it true that my eyelid may “fall” after THORACIC SYMPATHECTOMY?

A. In the past, when the surgery was performed through the cervical region (neck) or through the armpit region, there was a greater incidence of the CLAUDE BERNARD HORNER SYNDROME caused by the section or lesion of the stellate ganglion. Today, its incidence bares zero per cent. Dr. Marlos has never had a HORNER case within a range of six hundred patients that were submitted to the SYMPATHECTOMY procedure to HYPERHIDROSIS treatment.


9. Does THORACIC SYMPATHECTOMY can be done in patients of any age? Do kids can be operated?

A. The age of the patients operated by Dr. Marlos went from 8 years olds to 64 years olds. If the symptoms and limitations of the patients are important and affect their familiar and social life, if they affect their jokes and school activities, kids can be operated depending on the evaluation done by both doctor and family together.


10. I am anxious and have social phobia associated to Hyperhidrosis. Will the procedure heal these situations?

A. THORACIC SYMPATHECTOMY will stop the sweating on the affected spot. The patient must continue its anxiety and social phobia treatment with its psychologist or psychiatrist.


11. Is THORACIC SYMPATHECTOMY a risk surgery? May I die because of this operation?

A. THORACIC SYMPATHECTOMY is a low risk surgery, once done in healthy patients after the proper pre-operatory and pre anesthesial examinations are taken and analyzed. In case of patients under treatment of other specific diseases, SYMPATHECTOMY is only performed after the written permission of the assistant doctor. Very rare cases of death were straightly linked to THORACIC VIDEOTHORACOSCOPY SYMPATHECTOMY in world’s medical literature. We do not know of any patient that had died in Brazil as a consequence of THORACIC VIDEOTHORACOSCOPY SYMPATHECTOMY.


12. I used to have PALMAR and PLANTAR HYPERHIDROSIS. I’m healed of PALMAR HYPERHIDROSIS, but I did not obtain any success with PLANTAR HYPERHIDROSIS. Can I be submitted to another surgical procedure?

A. Yes, you can submit yourself to LUMBAR SYMPATHECTOMY, a procedure done with two incisions, one in each side of the abdomen.
 
HYPERHIDROSIS / BIBLIOGRAPHIC REFERENCES
Publications, seminars and conferences related to Hyperhidrosis


BIBLIOGRAPHIC REFERENCES
1. Gossot D, Toledo L, Frisch S, Célérier M. Thoracoscopic sympathectomy for upper limb hyperhidrosis: looking for the right operation. Ann Thorac. Surg, 1997 Oct, 64:4, 975-8.

2. Duarte JB, Kux P. Improvements in video-endoscopic sympathicotomy for treatment of palmar, axillary, facial, and palmar-plantar hyperhidrosis. Eur J Surg Suppl, 1998,: 580, 9-11.

3. Shachor D, Jedeikin R, Olsfanger, et al: Endoscopic transthoracic sympathectomy in the treatment of primary hyperhidrosis. Arch Surg 1994,: 129-241.

4. Edmondson RA, Banerjee AK, Rennie JÁ. Endoscopic transthoracic sympathectomy in the treatment of hyperhidrosis. Ann Surg 1992;: 215-289.

5. Zacherl J, Huber ER, Imhof M, et al. Long-term results of 630 thoracoscopic sympathicotomies for primary hyperhidrosis: The Vienna experience. Eur J Surg Suppl, 1998,: 580, 43-6.

6. Rex LO, Drott C, Class G, et al. The BorÁs experience of endoscopic thoracic sympathicotomy for palmar, axillary, facial hyperhidrosis and facial blushing. Eur J Surg Suppl, 1998: 580, 23-6.

7. Dumont P, Hamm A, Skrobala, et al. Bilateral thoracoscopy for simpathectomy in the treatment of hyperhidrosis. Eur J Cardiothorac Surg, 1997 Apr, 11:4, 774-5.

8. Cohen Z, Levi I, Pinski I, et al. Thoracoscopic upper thoracic sympathectomy for primary palmar hyperhidrosis. The combined paediatric, adolescents and adult experience. Eur J Surg Suppl, 1998,: 580, 5-8.

9. Lai YT, Yang LH, Chio CC, et al. Complications in patients with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy. Neurosurgery, 1997 Jul, 41:1, 110-3; Discussion 113-5.

10. Lin CC, Mo LR. Experience in thoracoscopic sympathectomy for hyperhidrosis with concomitant pleural adhesion. Surg Laparosc Endosc, 1996 Aug, 6:4, 258-61.

11. Moran KT, Brady MP. Surgical management of primary hyperidrosis. Br J Surg 1991; 78:279.

12. White JW. Treatment of primary hyperidrosis. Mayo Clinic Proceduce. 1986; 61:951.

13. Drott C, Claes G, Gothberg F, et al. Cardiac effects of endoscopic electrocautery of the upper thoracic sympathetic chain. Eur J Surg Suppl 1994,: 572, 65.

14. Adams DC, Wood SJ, Tulloh BR, et al. Endoscopic transthoracic sympathectomy: Experience in the south west of England. Eur J Vasc Surg 1992,: 6,558.

15. Ahn SS, Machleder HI, Concepcion BS, et al. Thoracoscopic cervicodorsal sympathectomy: Preliminary results. J Vasc Surg 1994,: 20,511.

16. Samuel L Moschella, Hany J Hurley. Dermatology. 3º ed Saunders. 1992: 1514-24.

17. Ernest G, Donald JG,Ronan OR. Anatomia. 4º ed Guanabara. 1988: 318-330.

18. Thomas MD. Thoracoscopic Sympathectomy. In: Chest Surgery Clinics of North America. Techiniques of Mediastinal Surgery. Saunders. Feb 1996: 6:1,69-83.

19. Hsu, CP, Chen, CY, Lin, CT, et al. Video-assisted Thoracoscopic T2 Sympathectomy for Hyperhidrosis palmaris.J. Amer Col. Surg., 1994 jul, 59-64.

20. Lee, DY. VATS Sympathectomy for essential hyperhidrosis. Jornal de Pneumologia – Supl., 1997 maio, s 21.

21. Saute, M, Sharony R, Bolotin Gil et al. Videothoracoscopic Sympatectomy – a Single port, drainless procedure for the treatment of palmar hyperhidrosis. S Am J. Thorac Surg. 1997 jan-apr;22-4.

22. Urschel, HC. Dorsal sympathectomy and manegement of thoracic outlet syndrome with VATS. Ann Thorac Surg 1993;: 56:717-20.

23. Ushijima, T Aakemoto K, Matsumoto Y et al. Surgical technique of endoscopic transthoracic sympathicotomy: axilary aproach. Kyobo Geka, 1998 Mar, 51:3,206-9.

24. Wong CW. Transthoracic videoendoscopic eletrocautery of sympayhetic ganglia for hyperhidrosis palmaris: special reference top localization of the first and second ribs.. Surg Neur, 1997 Mar, 47:3, 224-9.

25. Drott C ; Claes G. Hyperhidrosis treated by thoracoscopic sympathicotomy. Cardiovasc Surg, 1996 Dec, 4:6, 788-90.

26. Kao MC; Lin JY Minimally invasive surgery: video endoscopic thoracic sympathectomy for palmar hyperhidrosis. Ann Acad Med Singapore, 1996 Sep, 25-6, 673-8.

27. Kopelman D; Hashmonai M; Ehreinch M; Bahous H; Assalia A . Upper dorsal sympathectomy: improved intermediated-term results. J Vasc Surg, 1996 Aug 24:2, 194-9.

28. Noppen M; Herregodts P; Dhaese J; Vincken W. A simplified T2-T3 thoracoscopic sympathicolysis for the treatment of essential hyperhydrosis: short term results in 100 patients. J Laparoendosc Surg, 1996 Jun, 6:3; 151-9.

29. Shena, QS, Spira, M. Treatment of bilateral axillary hy peridrosis by suction-assisted lipolysis technique. Ann Plast Surg. 1987; 19:548-551.

30. Stenquist B. Axillary hyoperhidrosis: a simple surgical procedure. J. Dermatol Sug Oncol. 1985; 11:388-391.

31. Kotzareff, A . Ressection paritelle du trono droit du grand sympathique cervical pour hyperdrose unilateral de meme cote. Ver. Med. Suisse Romande, 1920 , 40: 111.

32. Levitt F. Simple device for treatment of hyperhidrosis by iontophoresis. Arch Dermatol. 1968; 98:505-507.

33. Lee DY. Needle Thoracic Symnpathectomy for Essential Hyperhidrosis: intermediate-term Follow-up. Ann Thorac Surg. 2000;69:251-3.

34. Claes G, Drott C, Göthberg G. Thoracoscopy for Autonomic Disorders. Ann Thorac Surg. 1993;56:715-16.
 
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