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ABSTRACT
Year : 2017  |  Volume : 2  |  Issue : 1  |  Page : 21-47

Abstracts presented for the 12th International Symposium on Sympathetic Surgery (ISSS), Fukoka, Japan


Date of Web Publication10-Jul-2017

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2542-4629.210000

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How to cite this article:
. Abstracts presented for the 12th International Symposium on Sympathetic Surgery (ISSS), Fukoka, Japan. Saudi J Laparosc 2017;2:21-47

How to cite this URL:
. Abstracts presented for the 12th International Symposium on Sympathetic Surgery (ISSS), Fukoka, Japan. Saudi J Laparosc [serial online] 2017 [cited 2017 Nov 17];2:21-47. Available from: http://www.saudijl.org/text.asp?2017/2/1/21/210000


  Lectures I Top


The history of sympathetic surgery

Moshe Hashmonai

Technion, Israel Institute of Technology (Retired)

Perfecting the anatomical and physiological knowledge of the sympathetic system allowed the advent of clinical sympathetic operations in 1889. The early operations were on the upper system and it was only in 1921 that the first lumbar sympathectomy was performed. Since these pioneering procedures, sympathetic surgery has substantially evolved. Early indications became obsolete. So is ischemia due to arterial occlusion, which was the major indication for sympathetic surgery during many decades. At present, primary hyperhidrosis is the main indication for sympathectomy. Several other indications are still valid, but rarely used. Thoracoscopy supplanted the four open approaches and endoscopy (either trans- or retro-peritoneal) replaced laparotomy. For upper thoracic sympathetic ablation, excision of the second thoracic ganglion alone or with the first and/or third ganglia was the standard during the open surgery era. With the advent of thoracoscopy a plethora of modifications related to the level, extent, and type of ablation were proposed in order to attenuate compensatory hyperhidrosis (CHH). It is possible that lowering the level, reducing the extent, and transecting the chain instead of excising/thermoablating the ganglia result in attenuating CHH, but this achievement is on the expanse of reaching a lesser degree of sweat reduction and a higher percentage of recurrences. The ideal operation for hyperhidrosis of the face and upper limb remains to be defined. To do so, controlled double blind studies with quantitative measurements of sweat production are required.

Overview of sympathectomy surgery including a short account of the history and indications for surgery

Chris Hensman

Monash University, Adelaide University, Medtronix Covidien Consultant

A detailed account of the history and indications for Sympathectomy Surgery in current practice. Literature review was undertaken of recent publications to support indications for Sympthectomy.

Current status of ETS in Italy

Mirco Santini1,2, Laura Vedana2, Lucia Scagliarini2, Claudio Bellucco1, Gabriele Anania3, Giorgio Cavallesco3

1Oncological Thoraco-Laparoscopic Surgery - IRCCS-CRO - Aviano, Italy, 2General Thoracic Surgery Unit - S.Anna Teaching Hospital - Ferrara, Italy, 3General Laparoscopic Surgery Unit - S.Anna Teaching Hospital - Ferrara, Italy

Endoscopic thoracic sympathectomy (ETS) is widely practiced among Italian Surgical Units. The presentation focused about the large variation of techniques among thoracic, general and vascular surgeons in Italy. The side effects and complications are aligned with the Literature. A need for evidence based consensus for indication, setting and anatomical level must be achieved in the next future with controlled double-blind studies.



A multi-center clinical data analysis of thoracic sympathicotomy in China

Yuanrong Tu

The First Affiliated Hospital of Fujian Medical University

Introduction: Endoscopic thoracic sympathicotomy (ETS) is currently the only effective and sustainable surgical treatment for disabling primary palmar hyperhidrosis (PPH). In this study, we evaluate the feasibility and safety of ETS in managing PPH by discussing key points, such as anesthesia method, operation method, choice of incision, ablation level of sympathetic nerve, and postoperative complications.

Objective: To provide medical evidence for clinical promotion of thoracic sympathicotomy. Methods: From January 2003 to July 2003, we analyzed clinical data collected from patients who underwent thoracic sympathicotomy at 15 institutions in China. The clinical data included patient's general data, anesthesia method, surgical equipment, choice of incision, ablation level of sympathetic nerve, postoperative complications, effectiveness, compensatory hyperhidrosis, recurrence, and satisfaction.

Results: There are a total of 9744 patients who underwent thoracic sympathicotomy. Among them, 5057 cases were male, and 4687 cases were female. The average age was 22.5 years, and 21.1% of the patients had positive family history. R3 (32.6%), R4 (26.6%) and R3-4 (25.0%) had been frequently selected as ablation levels of sympathetic nerve. The anesthesiologists often choose general anesthesia with single lumen intubation (62.4%), double lumen intubation (21.7%), and laryngeal mask (14.3%). Video-assisted thoracoscope is the most commonly used surgical equipment. But, some doctors would like to use mediastinoscope and flexible thoracoscope. Transaxillary single incision is the most frequently used incision. Other types of incisions included double incisions, three incision, transarolar single incision, and subxiphoid single incision. The effective rate of all institutions was greater than 99%, and the average effective rate was 99.7%. Compensatory hyperhidrosis (CH) occurred in 5206 patients (53.4%). Among them, 3289 cases (63.2%) were mild, 1670 cases (32.1%) were moderate, and 247 cases (4.7%) were severe. The most frequent locations were the back (44.5%), thorax (40.9%), abdomen (30.9%), thigh (24.8%) and calf (14.8%). Recurrent symptoms occurred in 73 cases (leaf hand 63 cases, right hand 57 cases), and 35 cases accepted re-operation and all healed. Average satisfaction rate was 97%.

Conclusions: ETS is a safe, effective and minimally invasive therapeutic procedure, which had a high rate of CH, but most cases were mild and moderate. ETS can be performed in routine clinical practice for PPH patients.

Clinical results of ambulatory endoscopic thoracic sympathectomy for palmar hyperhidrosis on more than 3800 consecutive cases in Japan

Hitoshi Oda

Oda Clinic, Day Surgery Center, Fukuoka, Japan

Ambulatory endoscopic thoracic sympathectomy (ETS) was performed on 3833 consecutive patients with palmar hyperhidrosis between October 2007 and March 2017 in my clinic. The average age at the operation was 28±10 years old, the onset age was 7±5 years old and the male-to-female ratio was 1:1.3. The mean operation time was 6±3 min. The patients were discharged within 3 to 4 hours after the surgery. Fourteen patients (0.4%) could not be discharged in the operation day due to complications; intraoperative bleeding in 2 cases, hemo-pneumothorax in 10 cases and subcutaneous hematoma or emphysema in 2 cases. On the early cases in my clinic, R4 ETS was done for palmar hyperhidrosis. After R4 ETS, patients had almost dry hands with less incidence of severe compensatory sweating in the 5-year follow-up, however 26 of 631 patients (4.1%) had secondary R3 ETS due to recurrence. Since July 2009, I've had a minor change of the procedure to R4 ETS with G3 cauterization; transection of the sympathetic trunk on the fourth rib and electrocauterization of the ganglion above the fourth rib. After R4 ETS with G3 cauterization, only 27 of 3202 patients (0.8%) underwent secondary R3 ETS due to recurrence. I have no analyzed data with comparison among R3 ETS, R4 ETS and R4 ETS with G3 cauterization. R4 ETS with G3 cauterization might be more effective than R4 ETS for palmar hyperhidrosis and might have less compensatory sweating than R3 ETS. Regarding recurrent cases after R4 ETS with G3 cauterization, if the patients desire the further operation, secondary R3 ETS can be performed easily without adhesion or scar tissues on the 3rd rib. It is estimated that the amount of compensatory sweating after unilateral ETS may be about half in comparison with that after bilateral ETS. Unilateral ETS only for a dominant hand was performed on 423 patients (11.0%) as a primary surgical procedure in my clinic. The patients after unilateral ETS shock hands without hesitation and used a pen with a dry dominant hand and that they were fully satisfied than expected. Almost 90 % of patients were very much satisfied, 10% were satisfied and none was discouraged. The degree of satisfaction in unilateral ETS was much higher than that in bilateral ETS, because the compensatory sweating was nothing or mild. Following unilateral ETS, the patients selected the other hand treatments after having experienced compensatory sweating. So far, 69 patients (16.3%) of 423 patients with unilateral ETS had secondary ETS for the other hand at least more than one year after the first operation. Nowadays, unilateral ETS cases were increasing in my clinic and about 40% of patients selected this operation in 2017. Unilateral R4 ETS with G3 cauterization may be one of the surgical strategies for the patients with palmar hyperhidrosis resistant to conservative treatments.

Internet-based remote medical education in Asia and beyond: Possible application to sympathetic surgery

Shuji Shimizu, Kuriko Kudo, Taiki Moriyama

Kyushu University Hospital

Internet has dramatically changed our lifestyle during the past few decades, for example, with emails and smartphones. Medical community is not an exception such that electric recording system and picture achieving communication system (PACS) are now common in daily practice. Although various attempts were made to take full advantage of this information and communications technology into medical education because of its time and cost benefit, many failed to transmit satisfactory quality of images in 1990s when there were lots of educational needs in endoscopic surgery. We here introduce our successful efforts to apply and expand this convenient tool to medicine. In 2002 when FIFA World Cup Soccer was co-hosted by Japan and Korea, these two countries were newly connected with super-fast Internet which was more than 300 times bigger than its conventional line. Using this advanced Internet together with another new technology called digital video transport system (DVTS), our team established the system for the first time in the world which enabled transmission of original quality of surgical images to remote sites in the satisfactory level to medicine. In contrast to the old systems with limited bandwidth where all the images must have been compressed and the quality was inevitably damaged, the new system allowed us to transmit moving images such as surgery without any loss of image quality. Another important point is its cost benefit such that the software is free and personal computers are used without purchasing costly special teleconferencing equipment. By November in 2016, we have performed 684 programs with 481 hospitals/institutions in 57 countries. Surgery accounted for 142 (21%) programs, next to gastrointestinal endoscopy (222, 32%), followed by fetus (31, 5%), and pediatrics (31, 5%). In surgery, there were 89 (63%) teleconferences and 53 (37%) live demonstrations. In 481 participating sites, 348 (73%) were located in Asia, but 47 (10%) in Latin America and 86 (17%) in the rest of the world. With recent renovation of new technologies, such as high-definition H.323 and Vidyo, the activities have been expanding to hospitals in rural areas with equivalent quality but with smaller bandwidth. Without geographical movement, remote education is convenient, saving time and cost for the travel especially when it is beyond the border of the country. At the same time, it is very efficient and effective for education because of participant scalability and easy repetition. We hope that remote medical education will continuously grow in many countries and will be applied in many fields including sympathetic surgery.


  Scientific Papers I Top


Comparison of microwave thermal-ablation & endoscopic R4-R5 thoracic sympathectomy for severe axillary hyperhidrosis

Kashif Irshad, Yuvan Khandelwal, Mankarn Grewal

William Osler Health System

Introduction: Axillary hyperhidrosis is a debilitating condition that results in excessive sweating in the underarms. Currently there are two well established long-term treatments: endoscopic thoracic sympathectomy (ETS) and microwave thermal-ablation (MTA)(Miramar Labs).

Objective: The objective of this study was to compare the effectiveness of MTA and ETS in treating axillary hyperhidrosis.

Material and Methods: Seventy patients that had undergone either ETS or MTA at a single institution (William Osler Health System in Ontario, Canada) were contacted via telephone. Prior to the consultation with the physician and their requested treatment, all patients had completed a questionnaire based on the Hyperhidrosis Disease Severity Scale (HDSS). The HDSS quantifies severity based on a scoring system between 1 and 4, with 4 being the most severe. Patients under the age of 18 were excluded from the study. Data was collected from 31 ETS patients and 34 MTA patients. Patient satisfaction, reduction in sweat, and level of compensatory sweating (redirected sweating due to the procedure) were assessed. Research Ethics Board (REB) approval was obtained prior to the study. ETS was performed using two, bilateral, 5 mm ports, with ablation of the sympathetic chain directly anterior to the 4th and 5th rib, without resection of the isolated nerve (Bilateral R4/R5 Sympathecotomy). The MTA device delivered 5.8 GHz microwave energy, heating the target tissue to 60 degrees Celsius. The energy from this device is reflected at the dermal-fat junction and becomes concentrated, creating a focal energy zone.

Results: Excellent improvement of hyperhidrosis, defined by a 2+ point increase on the HDSS, was seen in 80.0% of ETS patients who were reassessed less than 10 months following their surgery. However, this decreased to 69.2% in patients who were assessed more than 10 months following surgery. In the MTA cohort, 81.3% patients showed excellent improvement if assessed less than 10 months following the treatment. However, only 22.2% of patients who were assessed more than 10 months post-treatment showed excellent improvement. Compensatory hyperhidrosis occurred in 84% of ETS patients and 26.5% of MTA patients. For both ETS and MTA patients, the location of compensatory sweating was most often noted in the chest, back and abdomen.

Conclusion: Results indicate that MTA provides a temporary reduction in sweat, while ETS provides sustained sweat reduction. Prevalence of compensatory sweating due to MTA was drastically higher than reported in the literature. Further study is required to see whether a second course of MTA would be more effective than ETS in achieving long term sweating reduction.

Axillar curettage for the treatmet of axillary hyperhidrosis-long term follow-up

Gabriel Duarte, Joao Duarte, Arthur Duarte, Denise Duarte

Peter Kux Clinic

Introduction: Axillary hyperhidrosis is a frequent presentation of primary hyperhidrosis, which, when severe, may result in serious professional and social harm to its patients, even causing significant psychological disorders. Palliative treatments are not always effective in the most severe cases of axillary hyperhidrosis. Thoracic sympathicotomy, especially endoscopically, is an effective and definitive treatment for the vast majority of cases. However, compensatory sweating is of relevant clinical importance. Localized sympathicotomy associated with curettage of the deep dermis, of the axillary region, has been shown to be a highly effective surgical alternative for axillary hyperhidrosis, without changing the sweating in other areas of the body.

Objective: To evaluate, after a period minimum of 10 years, the efficacy of axillary curettage for the treatment of severe localized axillary hyperhidrosis.

Materials and Methods: During the period from June, 2000 to December, 2006, 50 patients with isolated severe axillary hyperhidrosis were operated on on an outpatient basis, totaling 100 surgeries. The area to be operated on was identified using the iodine test. The surgery consisted of the severing of the sympathetic nerve, followed by curettage of the deep dermis, of the previously marked axillary region. A prophylactic antibiotic was administered, which continued for 48 hours postoperatively. The results were based on a follow-up of the patients for at least 10 years.

Result: Most patients considered that axilar hyperidrosis was no longer a problem in their lives. The need for an analgesic, hematoma, infection rate, assessment of sweating in other parts of the body and return to normal activities, will be shown in specific graphs.

Conclusion: Axillary curettage has been shown to be an effective surgical treatment, with minimal adverse effects, in the vast majority of patients with severe axillary hyperhidrosis.


  Scientific Papers I / Scientific Papers II Top


Implementation of a symptom management education module for patients with palmar hyperhidrosis: A quality improvement initiative

Heather Givans1,2, Noel Perin1

1NYU Langone Medical Center, 2University of Massachusetts Boston

Introduction: Palmar hyperhidrosis causes excess sweating of the hands. This condition negatively affects patients socially and professionally. A systematic review of the literature revealed evidence that guided imagery and relaxation technique in this population contribute to symptom reduction. Rogers' theory of diffusion of innovation guided the implementation of this evidence-based project.

Objective: The purpose of this project is to implement a symptom management education module (SMEM) based on the current literature using guided imagery and relaxation techniques for patients with primary palmar hyperhidrosis. The goal of this project is to improve the patients' ability to cope with symptoms to reduce sweating and to improve quality of life. Materials and Methods: Five patients with palmar hyperhidrosis were seen during a 15 week period. During the first visit, a module consisting of a PowerPoint presentation with an overview of the pathophysiology of hyperhidrosis, cognitive restructuring and coping skills and relaxation with guided imagery was given. All of the patients underwent 2 evaluations: before the module and after (2-4 weeks) the module using a clinical questionnaire and a clinical protocol for quality of life.

Results: Following the implementation of the symptom management education module, 80% of the patients followed up after the initial visit. There was a decrease in disease severity after the education module. There was an increase in ability to cope after the education module. There was an increase in quality of life after the education module. 40% of the patients proceeded with surgery. The project is in the early stage of implementation and the sample size is too small to note statistically significance.

Conclusions: Implementation of a symptom management education module can provide guidance and encourage coping skills for patients with palmar hyperhidrosis.

Anesthesia for thoracoscopic sympathectomy – A 20 years experience

Abdelazeem Eldawlatly, Abdullah Aldohayan

King Saud University

Thoracoscopic sympathectomy (TS) for the treatment of palmar hyperhidrosis (PH) is gaining wide popularity. In the past, surgical treatment of PH was invasive and had a high incidence of morbidity. Because TS provides detailed visualization of the surgical field with minimal postoperative complications, most surgeons now prefer the thoracoscopic approach for the treatment of PH. Anesthesia for TS is challenging. Establishing one-lung anesthesia is an essential part of the anesthetic technique to facilitate adequate surgical exposure and better field visualization. One lung-collapsed ventilation (OLCV) can be achieved either by:

  1. endobronchial anesthesia using double lumen tubes or bronchial blockers with rocuronium/ sugammadex combination.
  2. capnothorax (CO2) insufflation combined with the use of a single lumen tracheal tube with rocuronium/sugammadex combination
  3. locosedation techniques and pneumothorax using non intubated video assisted thoracic surgery (NI-VATS) which goes with the new era of enhanced recovery after anesthesia (ERAA).


In this presentation we are going to describe different anesthetic techniques commonly used for TS in our practice which exceeded >500 cases. Also we are going to describe the NI-VATS technique and its role in ERAA.


  Scientific Papers II Top


Application of non-intubated anesthesia and spontaneous breathing in single-port thoracic sympathectomy for palmar hyperhidrosis by cystoscope

Kaibao Han

Nanjing Jingdu Hospital

Objective: To explore the effectiveness and safety of using cystoscope to replace thoracoscope in bilateral thoracic sympathectomy by non-intubated anesthesia and spontaneous breathing combined intercostal nerve block and pleura surface anesthesia in treatment of primary palmar hyperhidrosis.

Methods: From July 2014 to June 2016, we performed cystoscope to replace the thoracoscope in bilateral thoracic sympathectomy via a 5 mm incision in the treatment of 6 patients with palmar hyperhidrosis by non-intubated anesthesia and spontaneous breathing combined intercostal nerve block and pleura surface anesthesia. We selected semisupine position of 45°, abduction of the upper limbs for 90°, no operation position changing, the areola incisions in male, and the third intercostal incisions at the midaxillary line in female. The adhesive plaster was used to paste the incisions, without chest tube post operation.

Results: The operations were performed successfully in all 6 cases. No mortality or serious complications were observed during perioperation, no patient needed thoracotomy in the period of surgery. One case appeared left minor pneumothorax, 1 case had sinus bradycardia, and no complications of tracheal intubation were found. By follow-up for 1-26 months, we found 1 case of thoracodorsal compensatory hyperhidrosis, and no recurrence was found.

Conclusion: The use of sympathectomy by non-intubated anesthesia and spontaneous breathing combined intercostal nerve block and pleura surface anesthesia in treatment of primary palmar hyperhidrosis by cystoscope is safe, feasible, and effective. This surgical method can open to primary-level hospitals. However, more high-quality, multiple-center, large-sample randomized controlled trials are required.

Subxiphoid uniportal thoracoscopic bilateral sympathectomy for treating palmar hyperhidrosis

Jun Peng

Kunming University of Science and Technology Affiliated Hospital Objective: To explore a new operative procedure of subxiphoid uniportal thoracoscopic bilateral sympathectomy for treating palmar hyperhidrosis.

Methods: From February 2015 to July 2016, 28 patients with palmar, axillary or plantar hyperhidrosis, who were treated using subxiphoid uniportal thoracoscopic bilateral sympathectomy T3 and T4, were studied.We assessed many clinical data including the operative time, early complications and treating effect.

Results: All of 28 cases were successful. None of all conversion thoracotomy. Symptoms of hyperhidrosis vanished with both hands dry and warm in all the patients disappeared. Postoperative palmar temperature increased by a mean of (2.1± 0.5)°C. The operation time was 30±6.5 minutes on average. The most frequent postoperative immediate complication was postoperative 24 hours in 16(88.9%) patients.

Conclusion: Subxiphoid uniportal thoracoscopic bilateral sympathectomyis feasible, safe, micro-invasive and has shown good resultsfor treating palmar hyperhidrosis.

Animal experiment of percutaneous puncture to get sympathetic nerve chain guided by ultrasound at T3 level

Xiandong Tao

The Third Affiliated Hospital of The Second Military Medical University

Objective: Animal experiment, to explore the feasibility of a new technique, which using ultrasound equipment to guide the needle injection of drug on sympathetic nerve chain at T3 level, for the treatment of primary hyperhydrosis.

Methods: Adult pigs, prone position and fixed limbs after anesthesia. Use ultrasound equipment to detect sympathetic nerve chain on the level of T3 (i.e.around the 3rd rib head area ), the surface location is at the 3rd intercostal area paravertebrally. After probe is ready, pleural puncture needle is pushed into skin in the experiment area by 60 degrees to the skin. The ultrasound equipment guided needle to paravertebral sympathetic nerve chain region(i.e. rib head area) at T3 lever, without break the pleura, then inject methylene blue solution by 1ml through the needle, observe the reaction of pig after awake. Then anatomically observe the intrathoracic chest, to detect the methylene blue staining sites. Totally 3 adult pigs, each pig was taken bilateral experiments. Ultrasonic equipment is PHILPS iU22, using high-frequency probe, the probe frequency is 5~12MHz.

Results: Totally 3 pigs were operated with puncture bilateral. So the experiment was operated 6 times. There were no significant adverse reactions during or after the operation of the experiment. Anatomical observation showed: the first puncture broke the parietal pleura, resulting in leakage of methylene blue solution into the chest cavity, but didn't break the visceral pleura, the other 5 punctures didn't break the parietal pleura. Each puncturing reached the third intercostal paravertebral area(i.e. rib head area at T3 lever), methylene blue staining could been found in the punctureing area at the parietal pleura tissues, the diameter of staining was about 1~2cm. 3 times the sympathetic nerve chain was in the center of the dyeing area, 2 times in the periphery area of the dyeing point.

Conclusion: In experiment of pigs, ultrasound equipment can guide the percutaneous puncture needle to the sympathetic nerve chain area at the T3 lever, i.e. the intercostal space near the 3rd rib head area paravertebrally. By injecting certain drug, we may block the sympathetic nerve to treat primary hyperhidrosis. This technology is a feasible exploration direction. But the technique requires the operator to master professional ultrasonic anatomy knowledge and ultrasonic operation technology. At the same time, the chest wall can not be too thick, otherwise it is difficult to accurately display the anatomical structure by ultrasound equipment.

The imaging of thoracic sympathetic ganglions using indocyanine green near-infrared fluorescence: A potential precise method to localize the ganglions and guide the procedure for palmar hyperhidrosis

Ya nguo Liu

Peking University People's Hospital

Introduction: During sympathicotomy, the thoracic sympathetic ganglions are indirectly and roughly identified refer to the ribs. However, the exact position relationship between sympathetic ganglions and ribs remains inconstant because of the anatomical variations. This may result in the unstable curative effect of sympathicotomy. Thoracoscopic indocyanine green (ICG) near-infrared fluorescence is a novel method for visualization of tissues, organs, and tumors in surgical procedures. We discovered that the thoracic sympathetic ganglions, including the stellate ganglion, could be distinctly visualized under the near-infrared mode.

Objective: To examine the clinical application anatomy of upper thoracic sympathetic chain under indocyanine green near-infrared fluorescence.

Methods: 33 cases of thoracoscopic surgery patients were intravenous injected with 5mg/kg ICG 18-22 hours prior to surgery. In the operation, D-light P thoracoscope (KARL STORZ GmbH & Co, Germany) were used to detect near-infrared fluorescent light. Standard white light, near infrared fluorescence and Spectra A near-infrared fluorescent patterns were consecutively used to observe thoracic sympathetic chain.

Results: the whole set of all T2 - T5 sympathetic ganglia were visible under fluorescent in all patients. No adverse reaction occurred. By calculation, T2, T3, T4 and T5 ganglion located in corresponding intercostal space of the probability of 87.9%, 75.8%, 70.0% and 66.7%. Variable shift upwards, located in the upper rib surface (i.e. T2 ganglion is located in the second rib surface, and so on) of the probability of 3.0%, 9.0%, 12.1% and 9.0%. Shift downwards, located in the lower rib surface (i.e. T2 ganglion is located in the third rib surface, and so on) of the probability of 9.0%, 15.2%, 18.1% and 24.2%. This variation is the key why the curative effect of sympathicotomy is not stable. The fluorescence imaging technology can make up for the defects.

Conclusions: The method of preoperatively injection of ICG is reliable and safe in the imaging of thoracic sympathetic ganglions. This is the first report about fluorescent imaging of sympathetic ganglions, and this new finding may has great potential value in clinical application. It has promise for realizing direct and precise localization of the sympathetic ganglions and benefits the sympathicotomy for palmar hyperhidrosis.


  Scientific Papers II / Lecture II Top


What to do if you have an Azygos lobe

Abdulaziz AlMulhem, Abdullah AlDohayan, Abdelazim ElDawletly

King Saud University

Introduction: The azygos lobe is a rare finding, .1%-8% that was first described by Heinrich Wrisberg in1877. It develops from the failure of the lung bud to clear from the cardinal vein (future azygos vein) resulting in the splitting of the right lung.

Objectives: We would like to give an overview on how to handle a patient once encountering azygos vein and web.

Methodology: A retrospective study was done on five patients in our institute, King Khalid University Hospital in Riyadh.

Results: Azygos vein was left un-touched in all patients and dissection of the mesentery was enough for the proper exposure of the sympathetic trunk. The lung was re-inflated under visualizations and the azygos lobe was returned to previous place. No bleeding, infection or recurrence of symptoms was encountered in any of them.

Conclusion: Once encountering an azygos lobe, we advise to keep the vein and go through the mesentery. Dissecting close to the vein will pose a great risk of bleeding and it would be very difficult to control. Make sure to return the azygos lobe to it's original place as to decrease the chances of having a collection or infection.

Lumbar sympathectomy – Lateral retroperitoneal-Transpsoas approach – Results, advantages and disadvantages

Noel Perin

New York University Medical Center, NY, U.S.A

Introduction: Lateral flank incision, tubular retractor and operating microscope to access sympathetic trunk.

Objectives: Discuss results, complications, advantages, disadvantages of the approach.

Materials and Methods: Patients presenting with plantar hyperhidrosis had bilateral lumbar sympathectomy through a 1inch flank incision, retroperitoneal transpsoas approach using a tubular retractor. We performed 39 sympathectomies in 17 patients. Ages from 23 to 52, all but 1 patient were females. Preoperative hyperhidrosis severity scores, presence and severity of compensatory hyperhidrosis and post-operative outcome, both early and late and increase in compensatory sweating and recurrence of sweating were recorded. Follow up was performed up to 12 months, at 1,3,6 and 12months. The surgical technique has been previously published. All patients had the sympathetic chain cut at the L3-4 disc level.

Results: There were 39 Lumbar sympathectomies done on 17 patients, 37 procedures using this technique, 2 using the anterior Laparoscopic approach. 2 patients woke up with non- resolution of symptoms in 1 foot, 1 patient had partial resolution in 1-foot early and recurrence in 1 month. 2 patients had re-exploration of the one side using the same lateral trans-psoas approach. The late recurrence was successfully treated the 2nd time. The one male patient and 1 female patient with non-resolution of symptoms, we were not successful on the re- exploration. Both patients had an anterior laparoscopic approach, successful in the female patient, unsuccessful in the male patient; he was treated with Oxybutynin There were no intraoperative complications. No wound infections. 9 patients had compensatory sweating after prior ETS (Gr3) 8 of 9 patients reported some increase in CHH after surgery during exercise not interfering with ADL & required no additional treatment. The 9th patient was on Oxybutynin for CHH following prior ETS, no worsening and was put back on same dose of Oxybutynin.. One patient had excessive sweating of both hands and feet but elected to address the feet 1st, she came back 3months later for the ETS procedure. One patient with isolated plantar HH & odor, reported partial improvement in odor though the sweating abated. 6 patients had transient groin pain, in 1 or both sides, which resolved in 1-2 weeks. Groin and upper thigh numbness in 2 patients resolved after 3 weeks.

Conclusions: The lateral retroperitoneal trans-psoas lumbar sympathectomy was cosmetically pleasing, with minimal complications, has similar limitations in Obese & male patients with a bulky psoas as with the laparoscopic approach, the disadvantage is the re-positioning for either side. No C02 insufflation required.

Sympathetic ablation by clipping: How many clips are required?

Moshe Hashmonai

Technion - Israel Institute of Technology (Retired)

Introduction: Clipping is an acceptable technique for sympathicotomy. Practically all authors use at least two clips for that purpose, above and below the chosen ganglion. Is this necessary? The literature does not supply an answer.

Objective: To examine the validity of this approach based on the neuroanatomy of the upper sympathetic system.

Results: A human investigation (1) (by neurostimulation) showed that the sympathetic outflow to the upper limb and head originate from the anterior roots T1-T9 and ascend through the sympathetic chain to the stellate ganglion to be distributed to all target organs.

Implication: Transecting the chain at a certain level will block all lower ascending sympathetic fibers.

Conclusion: It is not required to clip the chain above and below a certain ganglion. Clipping above the ganglion should be sufficient.

CAVE: The so called nerve of Kuntz or simply ascending sympathetic fibers may bypass the level of transection and should be obliterated as well.

Reference: Ray BS, Hinsey JC, Geohegan WA. Observations on the distribution of the sympathetic nerves to the pupil and upper extremity as determined by stimulation of the anterior roots in man. Ann Surg 118:647-655, 1943.

Reversibility of unclipping the sympathetic chain – myth or fact?

Peter Licht

Odense University Hospital, Denmark

Sympathetic surgery is a well-established treatment for primary hyperhidrosis if non-surgical treatment options fail. The majority of patients develop compensatory sweating, which may be so severe that some patients request reversal surgery. For that reason many sympathetic surgeons have changed their surgical method from simple transection or resection to clipping the sympathetic chain because of potential reversibility if the clip is removed. For years, however, this topic has been controversial because of limited outcome data following reversal surgery. The number of studies that published clinical results following unclipping are slowly growing. They generally report that intolerable side effects ceased in the majority of the patients, but patients also reported that their primary hyperhidrosis complaints did not recur, which has fuelled speculations about a possible placebo effect of the reversal operation. The aim of this presentation is to update sympathetic surgeons about the current literature on reversal after clip removal.


  Lecture III / Scientific Papers III Top


Clip removal after endothoracic sympathetic block: 5-year results in patients with upper-limb hyperhidrosis

Georg Bischof1, Peter Panhofer2, Andreas Balogh2, Julia Jedamcik2, Andreas Gleiss3, Gerhard Prager2, Moritz Felsenreich2, Christoph Neumayer4

1Department of Surgery, Evangelic Hospital, Vienna, Austria, 2Division of General Surgery, Department of Surgery, Medical University of Vienna, Austria, 3Section for Clinical Biometrics, Center for Medical Statistics, Informatics, and Intelligent Systems,4Division of Vascular Surgery, Department of Surgery, Medical University of Vienna, Austria

Background: Reversibility of severe compensatory sweating (CS) has been controversially discussed after clip removal (CR) in patients with upper-limb hyperhidrosis (HH). The aim of this prospective study was to explore long-term outcome for the first time.

Methods: Postoperative HH and CS rates were graded from 0 to 10 on a visual analogue scale (VAS: 10 worst sweating) after endothoracic sympathetic block (ESB). Likewise, alterations after CR were evaluated. Moreover, patients' satisfaction was assessed. Follow-up investigations were performed at 9 months and 5 years after CR.

Results: A median follow-up of 87 months was completed in 24 out of 30 patients (80.0%). Severe CS significantly decreased 9 months after CR (VAS: 3.7; CI: 2.2–5.2; P<0.001) in 11 patients (45.8%). Five years after operation, 13 out of 23 patients (56.5%) experienced significant improvement of CS (VAS: 3.3; CI: 1.5–5.0; P=0.002). In none of the patients CS completely disappeared. HH rates deteriorated in 11 out of 23 patients (47.8%: 4 palmar HH and 9 axillary HH) after 5 years. 10 out of 23 patients (43.5%) were fully or partly satisfied after CR at long-term follow-up.

Conclusion: There is evidence of recovery of the sympathetic trunk after CR as half of the patients report improved CS even at long-term follow-up. Return of initial HH may impair patients' satisfaction, which should be considered for future patient information.

A comparative study of R4 versus R4+R5 sympathicotomy for primary palmar hyperhidrosis

Wenhan Weng

Peking University People's Hospital

Introduction: Primary palmar hyperhidrosis may interfere patients' social activity and professional life and this benign disorder frequently combined with axillary and plantar hyperhidrosis. Thoracoscopic R4 sympathicotomy has been recommended as a safer and effective surgical treatment procedure. According to the “Lin-Telaranta classification”, T5 controls the axillary sweating glands. Thus, R4+R5 sympathicotomy was applied for those patients who simultaneously suffered from axillary hyperhidrosis. However, no comparative study has been published to answer the question that which is the better option between R4 and R4+R5 for palmar hyperhidrosis.

Objective: To compare R4 with R4+R5 sympathicotomy in treatment of palmar hyperhidrosis and the severity of compensatory sweating.

Material and Method: A total of 419 consecutive patients with palmar hyperhidrosis from January 2005 to December 2014 were divided into two groups according to the symptomatic areas involved: group R4 underwent R4 sympathicotomy for palmar and/or plantar involved (n=281) and group R4+R5 underwent R4+R5 sympathicotomy for palmar, axillary and/or plantar involved (n=138). Follow-up was completed through phone call and e-mail. Patients were interviewed by using a pre-designed questionnaire which including the following contents: the degree of sweating improvement, grade of compensatory sweating and grade of satisfaction.

Result: All procedures were successful with no severe complications or perioperative mortality. A 30.7±25.4 months follow-up showed that there is no significant difference between two groups on the effective rate for palmar hyperhidrosis improvement and the satisfaction rate (96.8% vs 96.4%, p=0.822; 96.1% vs 96.4%, p=0.884). A total of 135 cases in group R4+R5 were involved with axillary hyperhidrosis and the effective rate for axillary hyperhidrosis improvement was 94.8%. One hundred and twenty-four cases in group R4 and 85 cases in group R4+R5 were involved with plantar hyperhidrosis respectively. R4+R5 sympathicotomy increased about 30 percent on effective rate of plantar hyperhidrosis improvement compared with R4 sympathicotomy (33.1% vs 60.0%, p<0.001). Moreover, the incidence rate of compensatory sweating after R4+R5 sympathicotomy was significant lower than R4 sympathicotomy (73.7% vs 63.8%, p=0.037). Although the total incidence rate of compensatory sweating in both groups were over 50%, only 2 cases (<0.5%) in group R4 showed an intolerable compensatory sweating among all cases.

Conclusion: Both R4 and R4+R5 sympathicotomy are effective treatment procedures for primary palmar hyperhidrosis. R4+R5 sympathicotomy may be a better choice for palmar hyperhidrosis because of lower incidence rate of compensatory sweating. A randomized controlled trial is needed to verify this conclusion. Moreover, R4+R5 sympathicotomy is recommended for the cases with axillary or plantar hyperhidrosis.


  Scientific Papers III Top


Hyperhydrosis: Safety & efficacy of thoracoscopic sympathectomy

Abdulaziz AlMulhem, Abdullah AlDohayan, Abdelazim ElDawlatly, Abdullah AlAqeel, Saad AlThwaini

King Saud University

Introduction: Hyperhydrosis represents both social and functional obstacle for affected patients. It can be classified to primary involving specific parts or generalized secondary to systematic disease or obesity. Different treatments modalities for primary hyperhydrosis have been tried, including surgical and non surgical ones. Topical ointments, systemic medications or local injections are examples of the non-surgical treatments with some drawbacks that limits their use. Surgery is considered as a next level of treatment and many authors believed that patient selection is important to get the best results. Different techniques of sympathetic nerve interruption have been done with no significant differences.

Objectives: We investigated whether thoracoscopic sympathectomy is efficient and safe in the treatment of hyperhidrosis.

Methodology: A retrospective study of 248 procedures from 1999-2015 done in King Khalid University Hospital in Riyadh. The study focused on resolution or improvement of symptoms, complications and recurrence among our patients.

Materials and methods: Patients were asked to answer a questioner in their follow up visit to Asses their satisfaction with the results.

Results: The average age of the group was between 20-40 with 73% being males. Family history of Hyperhydrosis represented 11%. Consanguineous parents was noted in 12.7%. The majority of patients reported palmer Hyperhydrosis, 88%. Clipping was the main choice in 96.8% of the patients. All cases underwent general anesthesia with single lumen tracheal intubation and capnothorax. Early complications were seen in 11% of the patient representing either pnoeumathorax or hemothorax. Recurrence of symptoms was reported in 20% ranging from mild to severe. Satisfaction was about 77.8% with psychological improvement while 4% regretted the procedure.

Conclusion: Hyperhydrosis is a disorder which should be dealt with. Thoracoscopic sympathetic clipping has proven to be an effective and safe option with offering both psychosocial benefit. Family history was not a main factor in determining a higher chance of having the problem.

Thoracoscopic highly selective sympathectomy

Abdulaziz AlMulhem, Abdullah AlDohayan, Abdelazim ElDawlatly

King Saud University

Background: Thoracoscopic sympathetic surgery is commonly used in management of hyperhidrosis, however, compensatory hyperhidrosis may limit the surgeries success. We introduced a new technique of cutting of the branches of the sympathetic chain, keeping the main chain, presuming to decrease the incidence of compensatory hyperhidrosis.

Patients and Methods: All patients who had hyperhidrosis and need surgery are enrolled in this study. Under general anesthesia with capnothorax of pressure 10 ml, 2 trocars size 0.5cm one in the midcalvicular line and the other one is in the posterior calvicular line, in the 5th inter costal space. The branches of the sympathetic nerve were cut. The branches coming out from the chain at the level of 3rd rib for hyperhidrosis Palmaris and T4 & TS for hyperhidrosis axillaries. After finishing the procedure, 20ml of Marcaine 0.125% was injected in the pleural cavity and the CO2 is suctioned and inflation of the lung with skin closure. Patients were seen in the OPD for follow-up.

Results: All 24 patients were operated as day surgery successfully. No patient developed significant compensatory hyperhidrosis during 1 year follow-up.

Conclusions: Highly selective sympathectomy is feasible, easy, with no clipping used and showed no significant compensatory sweating so far. Long follow-up is needed to estimate the benefits of the surgery.


  Scientific Papers III / Lecture IV Top


To leave or cut the nerve of Kuntz

Abdulaziz AlMulhem, Abdullah AlDohayan, Abdelazim ElDawletly

King Saud University

Introduction: The nerve of Kuntz was first described by a neuroanatomist in the University of St. Louis, school of medicine, named Albert Kuntz. He noticed an intrathoracic ramus between the second intercostals nerve and the ventral ramus of the first thoracic nerve which later which later gave a branch to the sympathetic trunk. After that, sympathetic intraneural connections were seen down to the fifth intercostals space.

Objectives: We would like to focus on whether cutting the nerve of Kuntz, while performing thoracoscopic sympathectomy for palmer hyperhydrosis, or leaving it would pose a risk on the patient prognosis on the long term and cause recurrence of his symptoms.

Methodology: A retrospective study was done on eight patient in our institute, King Khalid University Hospital in Riyadh. Four of our patient were male and the others were females. A two year clinical follow up was performed. Standardized assessment was done for all patient undergoing sympathetic chain clipping or cutting, including our group.

Results: At two years there was no recurrences of symptoms reported from any of our patient.

Conclusion: Dissecting near the area where the nerve of Kuntz passes is risky and with the use of two ports is quite difficult. We believe that there is no direct connection between the recurrence of symptoms with sparing of the nerve of Kuntz. Thus, leaving the nerve of Kuntz un touched would be advised. Further clinical follow up is needed.

Vascular injuries during ETS

Alan Cameron

Ipswich Hospital, Ipswich UK

This is a review of the author's experience in medico-legal cases following ETS. Several cases of venous, arterial and cardiac injury will be presented and the audience will be invited to offer suggestions about what went wrong and how to recover the patient. The author wishes to make it clear that these are not his personal patients!


  Lecture IV / Lecture V Top


The problem of pain?

Alan Cameron

Ipswich Hospital Ipswich, UK

The website www.no-ets.com which is very critical of ETS surgery states that “persistent or severe pain is unusual”. But is this correct? Four cases of patients who developed disabling neuropathy after ETS will be presented and the literature reviewed. The audience will be asked to estimate how of then this happens in their own cases

Facial blushing: How to select patients for Surgery

Claudio Suarez

Clinica Santa Maria, Chile

From the first publication about surgery in Facial Blushing by Drott in 1998(1) the number of patients treated by Endoscopic Thoracic Sympathectomy (ETS) was increase rapidly. Telaranta proposed to select patients with social phobia (2). Initially the satisfaction was about 85-88%, but decrease until 75% in the long follow up, and the regreat rate increase until 13,5% (3,4). There are no control studies until 2011, when Jadresic, Suarez et al published his work, they compare medical treatment (sertraline, IRSS) versus ETS, their results show 89% satisfaction with ETS and 59% with sertraline in long follow up. They recomend to select patients for surgery with previous medical treatment with sertraline for three months and operate just the non response group of patients. This way allows to diminish the regreat rate to 4% in long follow up (5) Licht et al published a randomized trial and compares R2 vs R2-3 sympathectomy, they show response rate 93%, with 85% satisfaction and regret rate 13% at one year follow up.(6) The recomendation to use first IRS for Blushing's treatment was confirm by Pelissolo and Moukheiber in 2013 (7) Based in this publications our group indicate surgery after psychiatric evaluation or, at least, social phobia questionnaries. Because the compensatory sweating is the main cause of regret we prefer thin patients for this surgery (BMI 20 or less). We think more BMI is associated with more sweating.

Our recomendations to select patients for surgery are:



  1. Severe Facial Blushing (degree 3-4 in a 0-4 scale)
  2. Psychiatric Evaluation to:

    - Discard another mental disease and

    - Diagnosis of Social Phobia / SAD

    - Evaluate capacity to understand bad results (compensatory sweating, persistent blushing, harlequin syndrome)


  3. Sertraline treatment prior to ETS
  4. BMI 20-22 max (< Compensatory sweating)
  5. Consider place of residence (climate)


Bibliography



1. Drott et al. Br J Dermatol 1998;138:639-43 Succesful treatment of facial blushing by endoscopic transthoracic sympathicotomy.

2. Telaranta T. Eur J Surg 1998; Suppl 580:27-32 Treatment of social phobia by ETS.

3. Dota C, Claes G, Olsson-Rex L et al. Br J Dermatol 1998; 138(4):639-43. Succesful treatment of facial blushing by endoscopic transthoracic sympaticotomy.

4. Smidfelt K, Drott C. Br J Surg. 2011;98(12):1719-24. Late results of ETS for hiperhydrosis an facial blushing.

5. Jadresic E, Suarez C, et al. Innov Clin Neurosci. 2011;8(11):24-35 Evaluating the efficacy of Endoscopic Thoracic Sympathectomy for Generalized Social Anxiety Disorder with Blushing complaints: a comparison with Sertraline and No Treatment- Santiago de Chile 2003-2009.

6. Licht PB, Pilegaard HK, Ladegaard L. Ann. Thorac. Surg. 2012 Aug; 94(2):401–5. Sympathicotomy for isolated facial blushing: a randomized clinical trial.

7. Pelissolo A and Moukheiber A. J Clin Psychopharmacol 2013;33: 695-698. Open-Label Treatment with Escitalopram in Patients With Social Anxiety Disorder and Fear of Blushing.




  Lecture V Top


Erythrophobia - where we are in 2017

Peter Licht

Odense University Hospital, Denmark

Erythrophobia is the fear of blushing. The pathophysiology of blushing remains a mystery and the exact incidence is not known. However, with increased awareness about this problem from the growing number of websites devoted to blushing one may expect that the number of patients who seek advise from sympathetic surgeons will continue to rise. The aim of this presentation on erythrophobia is to update sympathetic surgeons on the background and history of blushing, review the non-surgical treatments, advise on patient selection for sympathetic surgery and present clinical outcome as published in the literature.

R2 sympathicotomy with 5, 6, and 7th sympathetic ablation for craniofacial hyperhidrosis

Yo ung Woo Do1, Geun Dong Lee1, Eungbae Lee2, Sungsoo Lee1, SeokJin Haam3

1Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Severance University College of Medicine, Seoul, Korea, 2Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Medical Center, Daegu, Korea, 3Department of Thoracic and Cardiovascular Surgery, Ajou University Hospital, Suwon, Korea

Introduction: Craniofacial hyperhidrosis is a disease that may lead patients to serious emotional disturbances. Surgical treatment of craniofacial hyperhidrosis tends to be cautious due to complications and compensatory sweating.

Objectives: We aimed to evaluate the satisfaction and the pattern of compensatory sweating (CS) after R2 sympathicotomy with 5, 6, and 7th sympathetic ablation for craniofacial hyperhidrosis.

Material and Methods: Retrospective study was performed with 9 patients who had undergone thoracoscopic R2 sympathicotomy with 5, 6, and 7th sympathetic ablation for craniofacial hyperhidrosis between December 2015 and October 2016 at single institute. CS area were divided into 3 zone: upper zone included chest and mid back, mid zone included abdomen, waist, groin, buttock, and thigh, and lower zone included popliteus, calf, and sole. We analyzed the result of operation, grade of CS (none, mild, moderate, severe, very severe), area of CS, and grade of satisfaction (very satisfied, satisfied, moderate, dissatisfied, very dissatisfied).

Results: There were 7 (77.8%) males with the median age were 22 (range, 16-61). The median follow-up period was 119 days (range, 28- 214). There was no serious complication after surgery. Five patients were performed bilateral R2 sympathicotomy with 5, 6, and 7th transection of sympathetic nerve using electrocautery and 4 patient were performed bilateral R2 sympathicotomy with 5, 6, and 7th transection and longitudinal ablation of sympathetic nerve. There was no significant difference between two groups. The rate of very satisfied and satisfied grades of satisfaction was 88.9%. Eight patients (88.9%) had CS. For all of them, CS appeared in the mid zone. The rate of life-bothering CS was 22.2%.

Conclusion: R2 sympathicotomy with 5, 6, and 7th sympathetic ablation for craniofacial hyperhidrosis was effective and safe treatment with high satisfaction. Although CS was present in most cases, CS was limited to the mid zone and tolerable.


  Lecture VI Top


Sweat: more than skin deep. What we learned from dynamic analysis of the sweat gland

Hiroyuki Murota, Ichiro Katayama

Department of Dermatology, Graduate School of Medicine, Osaka University

Abnormal sweating is involved in the pathogenesis of dermatoses such as miliaria and atopic dermatitis. This pathogenic involvement has been explained in terms of the following etiologies: clogged sweat ducts, leakage of sweat from the sweat gland apparatus, and dysfunction of sweat glands. Recent advances in imaging techniques have enabled visualization of both the anatomical and kinetic characteristics of sweat glands, providing clues as to the underlying causes of sweating abnormalities. Here, I would like to present our recent research using those imaging techniques to analyze both sweat and sweat glands. First, in vivo observation of the skin by two-photon microscopy has enabled us to visualize the kinetics of sweat glands after sudomotor stimulus. This assessment can also evaluate blood flow around the sweat gland, demonstrating the coordinated activity between sweat glands and blood vessels. Using this method, we found that histamine directly affects sweat glands, inhibiting sweating without disturbing the motion of the sweat gland, and is involved in the pathogenesis of anhidrosis in allergic diseases. Second, to investigate the mechanism of sweat retention and leakage in dermatoses, visualization of the lumen of the sweat gland was performed by means of a fluorescent tracer. This technique confirmed that tight junctions in the paracellular space regulates the permeability of sweat glands. Allergic inflammation or sweat retention decreases the expression of claudins, major components of tight junctions, and the subsequent leakage of sweat may cause a tingling sensation during activities that cause sweating and may maintain the inflammation of allergic dermatoses. The dynamic analysis of sweat glands is a powerful tool to uncover the pathogenesis of abnormal sweating and will contribute to the development of a novel therapeutic approach.

Neural mechanisms of sweating on human hairy skin

Hiroshi Saito

Department of Neurology, Sendai Eastern Neurosurgical Hospital

Main function of eccrine grands on the hairy skin is heat dissipation under hot environment and exercise. Eccrine sweat glands are innervated by cholinergic postganglionic sympathetic neurons. The anterior hypothalamus and the preoptic area play a critical role in neural control of thermoregulatory sweating. The efferent fibers pass in the area ventral to ventro-lateral thalamic nuclei, then rostral and dorsal to the red nucleus. For further caudal course, main fibers pass down in the dorsolateral tegmentum of the brainstem, and further descend as a part of the reticulo-spinal tract to reach ipsilateral preganglionic neurons of the lateral horn. Some fibers may cross at various levels of the brainstem and the spinal cord. Thus, any lesions interrupting the pathways may result in mainly ipsilateral hypohidrosis. The skin area innervated by each spinal sympathetic segment is wider than corresponding sensory dermatomes. Those innervated by the upper thoracic and lower thoraco-lumbar segments differ considerably from the corresponding sensory dermatomes. Under physiological condition, thermal sweat rate is influenced by posture. That on the pressed side is suppressed largely, and that of the opposite side is moderately facilitaed. This “pressure-sweating reflex” may be of spinal mechanism. Various factors may influence activities of the hypothalamic thermoregulatory center. Stress and strain such as mental arithmetic exert mainly facilitation or less often inhibition on thermal sweating. A colorimetric qualitative sudomotor function test on the general body surface can provide information on the degree and the extent of the sympathetic deficits. Additional generalized or focal pharmacological sweat tests help to determine the level of the impairment. Continuous qualitative recording using a capacitance hygrometer is indispensable to elucidate dynamic aspects of the sudomotor sympathetic activities. Evaluations of various types of pathological hyperhidrosis are important to elucidate veiled neural mechanisms of sweating. Unilateral hemispheric or brainstem lesions may cause excessive spontaneous sweating on the opposite side of the body, possibly because of disinhibition from the cortical inhibitory influence. Continuous recording of the sweat rate in some of such subjects shows sweat expulsions of abnormally high frequency, suggesting hyperactivities of the spinal sympathetic neurons. In subjects with severe spinal damages, in addition to loss of thermal sweating below the lesion level, paroxysmal excessive sweating may occur often together with marked hypertension and heart rate reduction. This abnormal sweating is triggered by somatic and autonomic afferent inputs associated with bladder distension, painful bedsore, and so on. This is a released phenomenon from the tonic inhibition of possible medullary origin. Thus, pathophysiological mechanisms of hyperhidrosis appear far much complex than those of hypohidrosis, and many questions remain to be clarified.


  Lecture VII Top


Early outcome of tap water iontophoresis for palmar and plantar hyperhidrosis

Yo ung Woo Do1, Sungsoo Lee1, Geun Dong Lee1, SeokJin Haam2

1Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Severance University College of Medicine, Seoul, Korea, 2Department of Thoracic and Cardiovascular Surgery, Ajou University Hospital, Suwon, Korea

Introduction: Tap water iontophoresis has been used to treat palmar and plantar hyperhidrosis, although its mechanism of action is still not entirely understood.

Objectives: We aimed to evaluate the efficacy and safety of tap water iontophoresis for palmar and plantar hyperhidrosis.

Material and Methods: Thirty four patients who managed palmar and plantar hyperhidrosis by iontophoresis between July 2015 and August 2016 were retrospectively analyzed. The patients were received education and training at hospital, the maintenance treatments for 15-30 minutes a session every day were conducted using home device. Slowly increase the amperage until a tingling that is not unpleasant is felt in the affected area. The degree of sweating was measured using visual analogue scale (VAS) score (range, 0-10).

Results: The study group was composed of 16 men and 18 women, with a median age of 22 (range, 13-67). Median amperage of treatment was 3.5 mA (range, 2-8) for hand and 7.0 (range, 3-25) for foot. After median 14 days (range, 7-48) follow-up period, 29 patients (85.3%) were satisfied with tap water iontophoresis. Pre- and post- treatment median VAS score of hand and foot were significantly decreased (mean hand pre 8.7±1.6, hand post 4.3±2.5, p < 0.001; foot pre 8.7±1.8, foot post 4.6±2.1, P < 0.001). No serious complication was observed, except two case of vesiculation (5.9%) and two cases (5.9%) of burning sensation of the skin. Among 5 patients whose sweating was not decreased, 3 patients were received endoscopic thoracic sympathicotomy and 2 patients were followed without treatments.

Conclusion: Tap water iontophoresis was effective and safe treatment for palmar and plantar hyperhidrosis. Long- term follow-up including large sample size will be required to ascertain the efficacy and safety of tap water iontophoresis.

Local injection of botulinum toxin type A for palmar hyperhidrosis

Yuichiro Ohshima

Department of Dermatology, Aichi Medical University School of Medicine

Primary or secondary hyperhidrosis is excessive sweating beyond that required to return body temperature to normal. It can be focal or generalized and commonly affects the underarms, palms, soles or face. The disease often has a significant effect on the patient's quality of life. Commonly performed treatments include external application of aluminum chloride, oral intake of cholinergic blocking agents and antianxiety agents, iontophoresis using tap water, local injection of botulinum toxin type A, and endoscopic thoracic sympathectomy. Local injection of botulinum toxin type A in patients with palmoplantar hyperhidrosis has been reported to be effective in reducing the quantity of sweat produced. However, given the variations in dose and period of effectiveness, severity must also be taken into account when considering the dose. In our previous studies in which sweat production was measured using the ventilated capsule method, reduced sweating was observed for a period of approximately 6 months in patients with sweat production of approximately 1 mg/cm2 per min and who received local injections of 60 units (U) of botulinum toxin type A into one hand. However, because the effectiveness was limited in patients with sweat production of 2 mg/cm2 per min or more and a Hyperhidrosis Disease Severity Scale (HDSS) grade of 3 or higher, we increased the dose 1.5 fold in the present study, and we found that sweat production was reduced for a period of approximately 7 months. In a comparison of patients with sweat production of more than 2.5 mg/cm2 per min and an HDSS grade of 4 and patients with sweat production of 2.5 mg/cm2 per min or less and an HDSS grade of 3, there was no difference in the reduction of sweat production at 5 months, but the duration of the reduced sweating was shorter for the former group. This suggests that there are limits to the efficacy of botulinum toxin type A for severe forms of the disease with sweat production of more than 2.5 mg/cm2 per ml.


  Lecture VIII Top


Compensatory hyperhidrosis after endoscopic thoracic sympathectomy for palmar hyperhidrosis patients

Naoki Nishimura1,2

1Aichi Medical University School of Medicine, 2Nihon Fukushi University Faculty of Sport Sciences

Introduction: Endoscopic thoracic sympathectomy (ETS) is performed as a treatment for patients with severe palmar hyperhidrosis. After ETS, compensatory hyperhidrosis involving non-blocked sites, such as abdominal, dorsal, and femoral regions, is frequently observed. However, the pathogenesis remains to be clarified.

Objectives: We introduce the distribution of compensatory hyperhidrosis sites after ETS, and review that of sympathetic postganglionic fibers, which dominate the limb/trunk sweat glands.

Material and Methods: Sweating distribution after ETS was determined by the minor test (starch-iodine test) performed before and after ETS. An iodine solution is applied to the skin and allowed to air-dry. Once dry the area is dusted with cornstarch. After application of iodine solution and cornstarch, the patient rested for 30 minutes in a climate chamber set at ambient temperature 40° C (Relative humidity at 50%). When sweat reaches the surface of the skin the starch and iodine combine causing a dramatic color change to dark blue allowing sweat production to be actively visualized.

Results: Case 1: A 30-year-old male. After bilateral ETS, anterior thoracic, upper dorsal, and bilateral shoulder sweating at the same level (superior to the T4 level) between the left and right, as well as bilateral arm sweating, disappeared. On the other hand, marked symptoms of compensatory hyperhidrosis appeared in the face, abdomen, and bilateral lower limbs. Case 2: A 28-year-old male. After right ETS, sweating of the thorax, upper back, shoulder, and arm, superior to the T4 level, disappeared, and that of the face and neck also disappeared. On the other hand, the face, neck, and superior thorax on the non-operated side and left/right abdomen were slightly more darkly stained compared to those before ETS, suggesting a slight increase in the sweat volume. On the other hand, sweating of the right face and neck, which had disappeared after unilateral ETS, recurred after bilateral ETS. There was no laterality in the face or neck after left ETS. Furthermore, sweating of the left thorax and upper back (T3 to T5 level) disappeared, whereas that of the right thorax and upper back at the same level recurred. Sweating of the bilateral arms disappeared after bilateral ETS.

Conclusions: These findings are summarized below: (1) Even when ETS is performed at the same level between the left and right, subsequent sweat disappearance and compensatory hyperhidrosis sites are not always consistent. (2) Compensatory hyperhidrosis after bilateral ETS occurs vertically or horizontally. (3) Sweating disappearing after unilateral ETS may recur after bilateral ETS.

Reconstruction of sympathetic nerve with sympathetic nerve graft for compensatory hyperhidrosis

Hee Suk Jung, Doo Yun Lee

Bundang CHA Medical Center

Introduction: Compensatory hyperhidrosis (CH) is a potential complication following sympathetic surgery in the management of primary hyperhidrosis. Various reversal surgical techniques, aimed at reconstituting sympathetic pathways, have been developed but results have been inconsistent.

Material and Methods: We performed bilateral sympathetic nerve reconstruction with interpositional sympathetic nerve graft in nine patients with CH since July 2016. The subjected patients had presented severe CH with sweating on chest wall and abdomen after sympathetic surgery for primary hyperhidrosis. Sympathetic chain reconstructions were performed using free sympathetic nerve graft (T5-T8) by thoracoscopic surgery. Compensatory sweating after the reconstruction surgery was evaluated by D.I.T.I. (Digital Infrared Thermographic Imaging) with subjective symptoms.

Results: Postoperative results showed comparable improvement of excessive sweating on abdomen and chest wall in all patients. All patients were discharged in postoperative 4 days. There were no significant immediate postoperative complications.

Conclusions: Although long-term outcomes is limited, sympathetic nerve reconstruction using interpositional sympathetic nerve graft may be one of the useful surgical options for severe CH following sympathetic surgery for primary hyperhidrosis.

Characteristics of patients requesting reversal of sympathectomy

Cliff Connery, Sonya Alyea, Margaret Forte

Vassar Brothers Medical Center

Introduction: Our group has investigated the use of da Vinci Robotic assisted interposition nerve grafting to reconstruct the sympathetic nerve. We have been contacted by some who have undergone thoracic sympathetic nerve interruption for hyperhidrosis or blushing who are so dissatisfied with their post-operative quality of life that they inquire about reversal of sympathectomy. This occurs even if they have had satisfactory control of their primary symptoms.

Objectives: We report on the characteristics of those patients who contacted us in an attempt to better understand aspects of patients undergoing sympathectomy that may lead to dissatisfaction and to identify the cohort that is likely to ask for reversal surgery.

Materials and Methods: Phone contact summaries, forwarded outside medical records and in a few patients office visit records were reviewed and summarized for those requesting evaluation for sympathectomy reversal. Demographics, original symptom complex, levels of sympathectomy, time from operation to request for reversal were recorded.

Results: There were 47 (38 males, 9 females) individuals who provided enough information for analysis. Mean age was 34.9 yrs (range 22 to 65). The mean time from surgery to request for reversal was 6.1 yrs (Range 4 months to 19 years)

Original Presenting symptoms (some more than 1):

20/52 palmar

19/52 craniofacial and blushing

12/52 axillary

1/52 plantar

Of the 34 patients who provided op reports the levels interrupted were:

R2 7

R2,3 13

R2,3,4 8

R2,3,4,5 3

R3,4 ' 2

The R2 level was interrupted in all but one patient requesting reversal Data would indicate that patients dissatisfied to the point where they wish to be reversed have been suffering with side effects for more than 6 years on average. Males requested reversal much more frequently than females and were disproportionate to the relative percentage of males and females undergoing primary surgery in usual clinical practice. Most practices have a high percentage of patients operated with palmar symptoms. There appears to be a larger cohort of patients with craniofacial, blushing, and axillary symptoms requesting reversal than what is usually represented in a primary surgical sympathectomy practice.

Conclusions: While these data are not necessarily representative of all patients dissatisfied with sympathectomy, they provide additional support for careful selection of patients for treatment of craniofacial symptoms and blushing and the avoidance of R2 level interruption if possible. This group reinforces the concept that patients undergoing surgery for palmar symptoms have a durable improvement in quality of life which may account for the reduced request for reversal. If time from surgery to time of reconstruction impacts the success of the reconstruction procedure, the long time interval from primary surgery to request for reversal of these patients may affect results of nerve reconstruction. Additional study is needed to understand the rationales for the male predominance of the population requesting reversal.

Technical aspects of da Vinci robotic assisted sympathetic nerve reconstruction

Cliff Connery

Vassar Brothers Medical Center

Introduction: Some patients who have undergone sympathectomy for hyperhidrosis or blushing are dissatisfied due to severe side effects and wish that they could undergo reversal of sympathectomy. Those patients who have undergone sympathicotomy or sympathectomy can only be reversed with nerve interposition. Patients with clip interruption have reported reversal of symptoms with clip removal in some cases. Nerve reconstruction principles include selection of appropriate conduit, revision of transacted ends of nerve, interposition grafting without tension using magnification and direct suture.

Objective: We report how da Vinci robot technology is uniquely designed to facilitate this process. The use of magnified 3 d vision, distally articulated micro-instrumentation, allows performance of a precise nerve reconstruction adhering to principles while maintaining a minimally invasive approach. This reduces risk for complications and maximizes chance for nerve regeneration.

Material and Methods: Laboratory testing in acute and survival porcine model confirm technical feasibility, and histologic evidence of regeneration in survival animals. Experience with three generations of da Vinci Robot in patients will be discussed, as well as clinical outcomes in short and medium term. Intraoperative images and short video clip will illustrate.

Results: Initial clinical experience has confirmed our impression that da Vinci robot procedure will be associated with low morbidity, ready patient acceptance and in early follow up conclusive evidence of nerve regeneration by clinical criteria.

Conclusion: Sympathetic nerve reconstruction using the da Vinci robot for reversal of sympathectomy, maintains the principles of nerve reconstruction surgery using minimally invasive techniques and can provide an opportunity to improve quality of life in those patients dissatisfied after sympathectomy. Further clinical experience is necessary to better define the clinical characteristics of those patients most likely to benefit from sympathetic nerve reconstruction.


  Lecture VIII / Lecture IX Top


Treatment of compensatory sweating after sympathectomy with microwave thermal ablation

Christoph Schick, Silke Fischer, Kerstin Schick

German Hyperhidrosis Center, St-Bonifatius-Str. 5, D-81541 Munich, Germany

Background: So-called compensatory sweating (CS) is a compulsory sequila of upper thoracic sympathetic surgery. Treatment options for CS are limited and consist of anticholinergic drugs or reversal surgery because antiperspirants fail in most cases. Treatment succes is very limited. Microwave thermal ablation of glands with microwave energy is a new treatment option in focal axillary hyperhidrosis.

Objective: The objective if this study was to evaluate the effects of microwave ablation (MA) in the treatment of post-sympathectomy hyperhidrosis of the trunk based on subjective and objective criteria.

Methods: 15 healthy adults with severe CS after thoracic sympathectomy were treated with MA at the back, chest, and buttocks. The treatment area ranged from one to double letter size (600-1200 cm2). Amount of sweat was measured with gravimetry and visualized with Minor's test. Patients impairment was measured with Hyperhidrosis disease severity scale (HDSS) and Dermatology Life Quality Index (DLQI).

Results: All patient showed an improvement. MA treated areas showed a reduction of sweat production of more than 90%. HDSS normalized from 3.8 to 2.2 and DLQI from 16 to 6 respectively. No relevant complications were seen, no further “compensatory” effects occured in other body regions.

Conclusion: Microwave thermal ablation is a safe and efficient minimally invasive alternative in the treatment of CS. Limitations are treatment time and costs.

Physiological gustatory sweating and pathological gustatory sweating

Yo ko Inukai

Department of Physiology, Aichi Medical University School of Medicine

Physiological gustatory (noxious) sweating occurs reflexively and symmetrically in the facial skin and scalp when a healthy human eats typically spicy or acidic foods. The receptor in the oral cavity the above-mentioned foods, thus eliciting this localized sweating, is believed to be a capsaicin receptor known as the transient receptor potential cation channel subfamily vanilloid member 1 (TRPV1). TRPV1 is activated by nociceptive stimuli, noxious heat (43°C or above), and acidic stimulation. TRPV1 is expressed in epithelial cells and nociceptive fibers in the human oropharynx and larynx (Alvarez-Berdugo, 2016). Gustatory sweating efferent pathways might run through the cervical sympathetic trunk to reach the sweat glands on the facial skin and scalp. This is supported by evidence that sympathetic blockade of the stellate ganglion prevents gustatory sweating on the blocked side of the forehead (Drummond, 1995, Inukai, et al, 2003), and that physiological gustatory sweating can be removed by a sympathetic ganglionectomy (Nesathurai,1995). However, the gustatory sweating pathway may run differently from the thermoregulatory sweating pathway some parts, as demonstrated by a patient in our former study who has a deficit in hemifacial gustatory sweating but displays normal thermoregulatory sweating on that side (Inukai, et al, 2014). Brain temperature (measured by a thermistor for tympanic temperature) decreases during application of red pepper (consisting of capsaicin) on the tongue (Inukai, et al, 2003). Therefore, gustatory sweating elicited by TRPV1 may contribute to selective brain cooling in humans, protecting the brain from hyperthermia by activating feedforward regulation (Inukai, et al, 2016). Pathological gustatory sweating occurs such as Frey's syndrome or diabetes mellitus, but it can also occur after endoscopic upper thoracic sympathectomy or sympathicotomy (ETS). Frey's syndrome is characterized by flushing (vasodilation), warmth, and sweating of the face in the territory of auriculotemporal nerve when eating, which occurs several months to years after a traumatic or surgical lesion in the parotid gland region. It is hypothesized that parasympathetic nerves lesioned in auriculotemporal nerves regenerate aberrantly to sweat glands of the skin. Following ETS, gustatory sweating decreases for one week but then begins to increase within several months. In some patients, gustatory sweating would increase on the face and scalp and spreads to the neck and back, generally ipsilateral to the side of operation (data provided in personal communication by Dr. Hidehiro Yamamoto, Yamamoto-Hidehiro Clinic, Japan). Among 129 patients examined, enhanced gustatory sweating occurred more frequently (28.0%) in patients who underwent (right) unilateral sympathectomy at T2-5 (rib beds) compared with those who underwent the procedure at T3-5 (19.4%) (Yamamoto H, 2015). These data suggest that the second sympathetic thoracic ganglion is the most important structure for facial sweating. Based on these findings, it is possible that the underlying mechanism of gustatory hyperhidrosis after ETS is hyper-regeneration of sympathetic nerve fibers but not of parasympathetic nerve fibers as in Frey's syndrome, since excessive sweating following ETS is somewhat different from that in Frey's syndrome, as the former extends widely to the upper body and is not accompanied by flushing of the face.


  Lecture IX / Lecture X Top


The dual control theory for perspiration: A possible mechanism of gustatory sweating and compensatory sweating following sympathectomy

Naotoshi Tamura1,2

1Saitama Medical University College, 2Department of Neurology, Saitama Medical University

Gustatory sweating in the face and compensatory sweating in the trunk are the important side effects of sympathectomy for palmar hyperhidrosis. The mechanism of both phenomena is not known to date, but must be common to both, since these phenomena occur simultaneously in the same patient after sympathectomy. I am aware that both phenomena are easily explained by the dual control theory for perspiration, a forgotten antithesis against the present standard of perspiration physiology, which explained that perspiration is under the sole control of the sympathetic nervous system. I herein make a historical review on the dual control theory. Gustatory sweating: The earliest report suggesting the nervous control of perspiration came from Dupuy's horse experiment (1816), in which paradoxical sweating appeared in the face after cervical sympathetomy. Brown-Séquard (1849) presented his own physiological gustatory sweating produced by chocolate. Mentioning to Dupuy's horse experiment, Luchsinger (1876), a founder of perspiration physiology, suggested that gustatory sweating was caused not by the sympathetic nerves. Since Frey (1923) discovered gustatory sweating due to injury of the parotid glands, post-traumatic gustatory sweating has been explained by misdirection of the regenerated secretary parasympathetic fibres to the sweat glands. Physiological gustatory sweating is unable to be explained by the misdirection theory, however. Guttmann (1926), Wilson (1936), Kuno (1954), Monro (1959), Drummond & Lance (1987),and Licht & Pilegaard (2006) stated that the sweat glands in the face was under the dual control of the sympathetic and the parasympathetic nerves, and that the parasympathetic sweating was manifested when the sympathetic control was lost, or weak by nature. Since the presence of vasodilative parasympathetic fibres in the face skin is well-recognised, the dual control theory can comprehensively explain the mechanism of all cases of gustatory sweating, including post-sympathectomy gustatory sweating. Spinal parasympathetic fibres: Luchsinger (1876), through cat experiments, proved that perspiration is controlled predominantly by the sympathetic nerves, but also mentioned to the supplemental contribution of the parasympathetic nerves. Conversely, Langley (1891) stated that perspiration was under the sole control of the sympathetic nerves, denying Luchsinger's mention. Kuré, a founder of Japanese autonomic research, countered Langley's view. Kuré and his colleagues (1928) cut the dorsal spinal roots of dogs at the thoracic segments, and histologically investigated the central stumps of the dorsal root nerves after sustaining dogs alive for 3 months. In the transverse section of the dorsal root nerves, the entire large fibres were completely lost, while small fibres were preserved. They concluded that the dorsal root nerves contained efferent small fibres, and named these fibres as the spinal parasympathetic nerves. Kuré and his colleagues (1937) further demonstrated that electrical stimulation of the dorsal root, or the spinal parasympathetic fibres, produced segmental subtle sweating in shaved cats. After Langley's view was widely accepted, descriptions by Luchsinger and Kuré have been neglected without any challenge. If the trunk truly receives the spinal parasympathetic nerves, post-sympathectomy compensatory sweating may be also explained by the dual control theory. Conclusion: Post-sympathectomy paradoxical sweating may be a clue to substantiate the dual control theory.

Maturation-, aging-, and sex-related changes in sweating ability

Yoshimitsu Inoue

Osaka International University

This presentation reviews the maturation-, aging-, and sex-related changes in sweating ability using data (during passive heating, exercise, and cholinergic stimulation) obtained in our laboratory. Prepubertal children have an underdeveloped sweat ability (due to lower cholinergic sensitivity and/or smaller sweat glands) compared with that of young adults; this is compensated for by a greater surface area-to-mass ratio and relatively greater heat loss from cutaneous vasodilation on the head and trunk when air temperature is lower than skin temperature. As heat dissipation depends greatly on evaporation of sweat (air temperature > skin temperature), the core temperature of prepubertal children during exercise and/or heating is greater than that of young adults due to an underdeveloped sweating response. No sex differences in sweating ability are observed in prepubertal children. The degree of improvement by exercise training is markedly smaller in prepubertal children than in young adults. After puberty, sweating rates increase in both sexes, but the increase is smaller in females than in males. Therefore, young adult females have lower sweat rates than those of males. The sex differences in young adults are more marked in physically trained subjects compared with untrained subjects. Females have a superior sweating efficiency because they exhibit less-ineffective sweating (dripping of sweat), suggesting that the lower sweating rates of females may represent a biological attempt to control body fluid loss by reducing the amount of excess sweat that drips from the body in a hot, humid environment. Our cross-sectional and longitudinal findings suggest that the age-related decrease in heat loss effector function may involve cutaneous vasodilation, sweat output per gland, and active sweat gland density, in that order. The successive decrease may proceed from the lower limbs to the back of the upper body, the front of the upper body, then the upper limbs and finally to the head. Lower sweating ability in the elderly may be due to age-related alterations in peripheral mechanisms rather than central drive activity. From our recent results of a sweat expulsion test, a quantitative sudomotor axon reflex test by iontophoresis of acetylcholine, and a skin thermal sensitivity test in the same older and younger men, we also discovered an age-related change in the sweat gland itself (atrophy and/or lower sensitivity to cholinergic stimulus) and in the sensitivity of skin thermoreceptors that may precede the decrease in the activities of the central sudomotor and sympathetic nerves. Sex differences in sweating ability decrease with aging and tend to disappear in people in their 80s. Regular exercise slows and improves the age-related decline in sweating ability. We found recently that the elderly can maintain sweat gland function equal to young long-distance runners through marathon training, although decreased sweat function was observed on the thigh (body site on which age-related decrement occur early) in elderly runners.


  Lecture X Top


Surgical tratment of hyperhidrosis in children and adolescent

José Ribas Milanez deCampos, Hugo Veiga Sampaio

daFonsca

Department of Thoracic Surgery of São Paulo University Medical School

Introduction: Primary Hyperhidrosis (PH) is a somatic disorder that results from hyperfunction of the sympathetic nervous system(1). It usually starts during childhood(2), has a symmetric distribution and a similar prevalence in both sexes and affects 2.8% of the population. PH can lead to social, professional and emotional problems that are associated with low levels of quality of life (QOL)(3). The palmar and plantar regions are the most commonly affected sites in this age group. The mother usually notices the symptoms of PH, and when parents seek medical help, they cannot find data from the literature to help them make an objective decision regarding the best time to use surgical treatment.







Clinical Management: Oxybutynin is a cholinergic antagonist that is used to treat pollakiuria and hyper-refectory urine bladder, and it is generally used at a dose of 10 to 15 mg per day. In children, oxybutynin has been routinely used to treat urologic conditions, particularly nocturnal enuresis. The first case reporting the collateral effects of oxybutynin in a man with urinary urgency was in 1988, which presented with a improvement of his symptoms of excessive sweating. Many other reports were published, including with specific population such as children. We did not use an objective measurement of sweating to evaluate the response to treatment because the methods available produce data at only a specific time(14). There are no methods capable of evaluating the level of hyperhidrosis for an entire day. For this reason we suggest the child's perception of QOL as a surrogate for objective improvements in sweating. Furthermore, the goal of any treatment for primary hyperhidrosis is to improve the patient's QOL. Considering that the main treatment for palmar and axillary hyperhidrosis is surgical and that the side effects of such therapy are significant, oxybutynin represents a possible alternative. In a prospective, controlled, randomized, blind trial in 50 patients with axillary and palmar symptoms between 18-50 years old, a comparison of the effects in quality of life of Oxybutynin against placebo was performed. Hyperhidrosis improved in more than 70% of patients, and 46.8% of those presented great improvement. Plantar hyperhidrosis improved in more than 90%. Most patients (65%) showed improvements in their quality of life with minor side effects (dry mouth in 47%).

Surgical Treatment: In adults, video-assisted thoracic sympathectomy (VATS) is one of definitive treatment options; it is a safe procedure with good results, although it is associated with compensatory hyperhidrosis (CH), which occurs in virtually all patients with greater or lesser intensity, mainly on the trunk, with an unknown pathophysiology. In children, VATS has been used in daily practice, apparently with the same safety and good results as adults, although there are few scientific studies, especially for its indication in children. It is also unknown whether surgery performed on children younger than 14 produces better results than clinical management after a longer period. The best way to evaluate this question is to measure the QOL in these groups after a long period of time. We performed a prospective nonrandomized study which evaluated forty-five children with PH younger than 14 at the time of first consultation(18). Thirty children underwent VATS, and 15 children were in the control group and not treated with anything. Patients answered a questionnaire about their clinical improvement according to their subjective perception of improvement in hyperhidrosis on a scale from 0 to 2 (0 = no improvement, 1 = partial improvement, and 2 = no hyperhidrosis). The negative effect of hyperhidrosis on QOL before the treatment was classified into five different levels and calculated as the summed score from the protocol (range from 20 to 100): the higher the level, the greater the effect, and the poorer the QOL (>84, very poor; 68–83, poor; 52–67, good; 36–51, very good; and 20–35, excellent). Improvement in QOL after the treatment was classified using five levels (>84, much worse; 68–83, worse; 52–67, no change; 36–51, some improvement; 20–35, much better). Changes in PH after 4 years are presented in [Table 2]. Twenty-five patients (83.4%) in the VATS group experienced great improvement in PH, and five (16.6%) experienced partial improvement; 12 (80.0%) children in the control group had no improvement, and three (20.0%) had partial improvement. CH was observed in 27 children who underwent VATS at the last assessment; 19 had slight CH and eight had severe CH. The most frequent locations were the abdomen (18) and back (25), then the thighs (7), buttocks (6), and lower legs (6). Improvement in QOL is presented in [Table 4]. Two patients (13.3%) in the control group and 23 (76.7%) in the VATS group were much better than at the first evaluation.





The children who sought medical assistance were discontent with their PH. The degree of negative effect on their QOL was measured in our study using a specific QOL questionnaire on hyperhidrosis that has been validated for adults and used in several published studies. The degree to which hyperhidrosis worsens a patient's QOL depends on the severity of the condition and the patient's adaptation to each situation, even in childhood. Some children with milder hyperhidrosis have very poor QOL, but other children with very severe hyperhidrosis may report that their QOL is not so poor because they have adapted more successfully. All of the children in this study had poor or very poor QOL. Almost all patients who are healthy can be treated with VATS except for small or obese patients, who might have a greater risk of CH after surgery and are a higher surgical risk. We observed that children who reported CH presented such symptoms immediately after the surgery but only during periods of very hot weather, during exercise, and occasionally correlated with stress. The results from the treatment of PH were more satisfactory in the VATS group. The children in the control group had QOL levels that were statistically lower. Palmar sudoresis was lower in more than 80% of the cases after surgery. The VATS group had an improvement of 76.7% with regard to QOL, but only a 20% improvement was noted in the control group. The results of VATS are outstanding because more than 95% of patients become free of or show improvement in PH, although this improvement is often at the cost of CH (an irreversible increase in sudoresis in other parts of the body). The factors that are currently associated with a worsening of QOL after thoracic sympathectomy for the treatment of hyperhidrosis are surgical failure and severe CH(31), which were not present in our series. In contrast, we observed improvement in only six patients, and nine patients were the same or worse in the QOL evaluation with conservative treatment (controls). We have shown that children younger than 14 with PH and low QOL have better results in improving their QOL after undergoing VATS.


  Lecture X / Lecture XI Top


Clinical results of endoscopic thoracic sympathectomy for elderly patients and children with palmar hyperhidrosis

Hitoshi Oda

Oda Clinic, Day Surgery Center, Fukuoka, Japan

Introduction: The patients with palmar hyperhidrosis (PH) have been suffering from the symptoms since they were children and their troubles will continue until they get old. Objectives: The aim of this study is to elucidate the clinical efficacy and patient satisfaction of endoscopic thoracic sympathectomy (ETS) for elderly patients and children with PH.

Materials and Methods: Between October 2007 and April 2016, 20 elderly patients with PH of 60 years old and over (60-77 years old, 11 men and 9 women) and 46 children with PH of 12 year old and under (8-12 years old, 16 boys and 30 girls) underwent R4-ETS in my clinic. Of 46 children, 38 cases (82.6%) had a family history. In 21 children (21.9%), their parents and/or older brothers and sisters had been performed R4-ETS in my clinic previously. All elderly patients desired bilateral R4-ETS and 18 of them (90.0%) underwent bilateral R4-ETS as planned, however 2 of them (10.0%) underwent unilateral R4-ETS due to severe intrathoracic adhesions. In children with PH, 39 cases (84.8%) underwent bilateral R-4 ETS and 7 cases (15.2%) underwent unilateral R4- ETS for dominant hand as they and their parents wished. Nineteen of 20 elderly patients (95.0%) and 39 of 46 children (84.8%) were available with a follow-up (2-97 months) by a telephone questionnaire with a scoring system.

Results: All elderly patients improved PH; 17 patients (89.5%) had dry hands and 2 patients (10.5%) had almost dry hands after R4-ETS, and none of them recurred during follow-up periods. On the other hand, 18 of 39 children (46.2%) had dry hands and 11 children (28.2%) had almost dry hands after R4-ETS, however 4 patients (10.3%) had occasionally slightly wet hands and 6 children (15.4%) recurred, and 3 of them underwent secondary R3-ETS. In 19 elderly patients, compensatory sweating (CS) was observed in 8 patients (42.1%); 6 patients (31.6%) with minor CS, 2 patients (10.5%) with moderate CS but none with severe CS. Two elderly patients had gustatory sweating after ETS. In 32 children performed bilateral ETS, CS was observed in 16 patients (50.0%); 14 patients (43.8%) with minor CS, 1 patient (3.1%) with moderate CS and 1 patient (3.1%) with severe CS. While in 7 children performed unilateral ETS, CS was observed in 2 patients (28.6%) with minor CS but none with moderate or severe CS. Overall, in elderly patients, 17 patients (89.5%) were very much satisfied and 2 patients (10.5%) were satisfied. In children performed with bilateral ETS, 21 patients (65.6%) were very much satisfied and 6 patients (18.8%) were satisfied, however 5 patients (15.6%) regretted the procedure due to CS or recurrence of wet hands. In children performed with unilateral ETS, 5 patients (71.4%) were very much satisfied and 2 patients (28.6%) were satisfied. One of children (14.3%) performed unilateral ETS had the other unilateral ETS in one year after the first operation and two of them (28.6%) intended to have the second operation for the other hand in the near future, while other 4 children (57.1%) were fully satisfied with a dry dominant hand and did not desire the further operation so far.

Conclusions: In elderly patients with PH, ETS can be performed effectively for PH with less incidence of severe CS, which results in providing excellent patient satisfaction. On the other hand, regarding with ETS for children, the recurrence rate seems to be relatively high and it is difficult for children to understand completely an informed consent for CS. Therefore, ETS for children should be chosen only in a serious trouble such as insupportable bullying due to PH, and especially in children, unilateral ETS is recommended for the first surgical treatment.

The “Etiology” of primary palmar hyperhidrosis

Moshe Hashmonai1, Alan Cameron2, Cliff Connery3, Noel Perin4, Peter Licht5

1Technion - Israel Institute of Technology (Retired), 2Ipswich Hospital, Ipswich, UK, 3Vassar Brothers Medical Center, 4New York University Medical Center, NY, U.S.A, 5Odense University Hospital, Denmark

Introduction: Primary hyperhidrosis is a pathological disorder of unknown etiology, affecting 0.6-5% of the population, causing severe functional and social handicaps. As the etiology is unknown it is not possible to treat the root cause. Recently some differences between affected and non affected people have been reported.

Objectives: The aim of this review is to summarize these new etiological data.

Methods: Search of the literature was performed in the PubMed/Medline Database and pertinent articles were retrieved and reviewed. Additional publications were obtained from the references of these articles.

Results: Some anatomical and pathophysiological characteristics (as well as enzymatic, metabolic and neurological dysfunctions) have been observed in hyperhidrotic subjects; three main possible etiological factors predominate. A familial trait seems to exist and foci for hyperhidrosis have been found on chromosomes. Histological differences were observed in sympathetic ganglia of hyperhidrotic subjects: the ganglia were larger and contained a higher number of ganglion cells. A higher expression of acetylcholine and alpha-7 neuronal nicotinic receptor subunit in the sympathetic ganglia of patients with hyperhidrosis has been reported.

Conclusions: Despite these accumulated data, the etiology of primary hyperhidrosis remains obscure. Nevertheless, three main lines for future research seem to be delineated: genetics, histological observations, and enzymatic studies.


  Lecture XI / Scientific Papers IV Top


Emotional sweating and autonomic neuroscience research in Japan: The past and the present

Masato Asahina

Neurology Clinic Tsudanuma & Institute of Neurology

Current anatomical concept of the autonomic nervous system was established by John N. Langley in his book “The Autonomic Nervous System” in 1921. Ken Kure introduced Langley's achievements to Japan in 1934. He also introduced thermoregulatory sweat test (Minor's method) to Japan. Subsequently, Shigeo Okinaka, a pupil of Kure, published the first Japanese textbook on clinical autonomic function tests including galvanic skin reflex (electrodermal activity) in 1947. Yas Kuno accomplished a great achievement in the field of perspiration research, and developed a quantitative method using dry air and calcium chloride desiccant to measure focal sweating (1934). However, this method needed a large laboratory chamber. Several Japanese pioneers made numerous improvements in the device. Recently, we can use a compact sudorometer using hygrometers to evaluate palmar sweating, so-called emotional sweating, as well as recording of electrodermal activity. Evaluation of palmar sweating is helpful to diagnose neurological disorders such as multiple system atrophy, Parkinson's disease, pure autonomic failure and several neuropathies. In addition, measurement of palmar sweating is helpful to evaluate efficacy of thoracic sympathectomy for palmar hyperhidrosis.

Endoscopic transthoracic sympathectomy is a safe and useful option for severe intractable angina and catecholaminergic polymorphic ventricular tachycardia

Mitsuhiro Kamiyoshihara, Natsuko Kawatani,

Takashi Ibe, Fumi Ohsawa, Ryohei Yoshikawa

Maebashi Red Cross Hospital

Introduction: Intractable angina and catecholaminergic polymorphic ventricular tachycardia is a rare but severe cardiac disease that carries a risk of sudden cardiac death. The purpose of this study was to assess the feasibility and usefulness of endoscopic transthoracic sympathectomy (ETS) for this disease.

Methods: From 2010 to 2016, six patients who were unable to tolerate, or who were refractory to, medical therapy underwent ETS. Under general anesthesia, the pleural cavity was entered through two 5-mm incisions in the subaxillary area. The thoracic sympathetic chain was identified, and the T2 to T4 sympathetic chain was cauterized and resected using a bipolar energy device on the right and left sides, respectively.

Results: The mean patient age was 53 years, and the male to female ratio was 3:3. The diseases included intractable angina in five patients and catecholaminergic polymorphic ventricular tachycardia in one patient. Of these, three patients had a previous history of cardiac arrest. The mean operative time was 81 ± 10 min. Blood loss was minimal. The median postoperative stay was 16.0 days and the median follow-up period was 37.2 months. There were no major complications in the intra- and postoperative courses. Postoperatively, the frequency of cardiac attacks decreased from 2.3 times per day to 1 every few months. No syncopal events have occurred to date. The mean medicine dosage decreased from 6.6 drugs to 2.6.

Conclusions: ETS is a safe and effective treatment option for patients with intractable angina and arrhythmia refractory to medical management.


  Scientific Papers IV Top


Extent of sympathectomy affects postoperative compensatory sweating and satisfaction in patients with palmar hyperhidrosis

Tetsuya Sakai, Taku Fukano

Sasebo Kyosai Hospital

Introduction: Endoscopic thoracic sympathectomy (ETS) for the treatment of palmar hyperhidrosis is generally performed at one or two levels ranging between T2 and T4; however, compensatory sweating (CS) is an occasional bothersome side effect.

Objectives: The aim of our study was to evaluate the association between the extent of ETS and the degree of postoperative CS and palmar sweating, as well as patient satisfaction.

Material and Methods: The participants represented a consecutive series of 76 patients who underwent bilateral ETS for palmar hyperhidrosis at level T2 and/or T3. Patients were interviewed by postal questionnaires to assess their self-reported degree of postoperative palmar sweating and CS and their outcome satisfaction. Of the 53 patients who replied to the postal questionnaire, 25 underwent bilateral ETS at one level (group A), and 27 underwent bilateral ETS at two levels (group B). One patient who underwent asymmetrical sympathectomy was excluded.

Results: The degree of postoperative palmar sweating was significantly lower in group B than in group A. The severity of CS was significantly higher in group B than in group A. The severity of CS was significantly inversely correlated with the degree of patient satisfaction. However, the degree of postoperative palmar sweating was not correlated with the degree of patient satisfaction.

Conclusions: Compared to ETS at two levels, single-level ETS of T2 or T3 reduces postoperative palmar sweating to a milder degree, and causes CS to a less severe degree. The severity of CS is inversely correlated with the degree of patient satisfaction.

Compensatory sweating of endoscopic thoracic sympathectomy of T3 and T4 for palmar hyperhidrosis

Michiko Kitagawa, Yoshimochi Kurokawa, Yosuke Seki, Akiko Umezawa, Kazunori Kasama

Yotsuya Medical Cube Objective: Palmar hyperhidrosis is very serious for patients and this symptom compromises their quality of life. Endoscopic thoracic sympathectomy (ETS) is effective for treating palmar hyperhidrosis. However, compensatory sweating (CS) is an annoying side effect of ETS. We analyzed the occurrence rate of CS and patients' satisfaction.

Methods: From January 2016 to September 2016, 277patients with palmar hyperhidrosis underwent bilateral ETS of T3 and T4. The mean age was 27.5±10.5 years, with a range of 13-70. The patients received follow-up on an outpatient basis after 3 months of surgery and we checked the degree of postoperative palmar sweating (dry, decreased, persistent or increased), complications including CS. We also evaluated the sites of CS.

Results: 162patients (58.5%) were followed postoperatively and the mean follow-up was 3.17 months. 97.5% (158patients) had completely dry palms. 1.9% (3 patients) had mild sweating and only one patient had a recurrence of palmar sweating and underwent bilateral ETS of T2. The incidence of CS was 94.4% (153 patients). However, severe CS which require medical treatment was5.2% (8patients) and almost patients with CS answered that they didn't mind at all about it. CS occurred most frequently on the back in 63.4%, followed by thighs (53.6%) and abdominal reason (33.3%). There were no cases of mortality, no significant postoperative complications, and no need for conversion to thoracotomy.

Conclusions: Bilateral ETS of T3 and T4 is a safe and effective procedure to treat primary palmar hyperhidrosis. CS is high incidence after this procedure. However, the degree of CS is mild for almost patients and severe CS is rare. Palmar hyperhidrosis is very serious for patients and this procedure has shown to significantly improve the quality of life.


  Scientific Papers IV / Lecture XII Top


Comparison of thoracic sympathotomy outcomes in patients with palmar hyperhidrosis: the cutting versus clamping methods

Masayuki Nakagawa1, Kumiko Hida2, Tetsuya Sakai2, Yoichiro Abe1

1NTT Medical Center Tokyo, 2Nagasaki University School of Medicine

Introduction: Endoscopic thoracic sympathectomy (removal of sympathetic chain and/ or ganglion)/ sympathotomy (interruption of sympathetic chain without removing ganglion) for the treatment of palmar hyperhidrosis is generally performed by either cutting or clamping the sympathetic chain. However, it remains unclear as to which of these methods is more effective and has fewer side effects.

Objectives: The objective was to compare the effects of sympatotomy at T3 level for palmar hyperhidrosis by cutting and by clamping on postoperative palmar sweating, compensatory sweating, and patient satisfaction. We also evaluated associations among postoperative outcomes.

Material and Methods: The procedure was performed under general anesthesia in the semi-seated position with a double-lumen endotracheal intubation. Two 5-mm trocars were inserted. The sympathetic chain was either transected completely or clamped by a clip. Transection was performed with electrocautery at the T3 rib bed, and an autosuture endscopic clip was placed above or below the T3 rib using the 5-mm endoclip applier. The participants represented a consecutive series of 289 patients who underwent bilateral thoracoscopic sympathotomy at T3 for medically refractory palmar hyperhidrosis at the NTT Medical Center Tokyo between January 2004 and December 2010. In May 2013, the patients were asked to fill out postal questionnaires to assess operative outcomes after sympathotomy, such as the degree of postoperative palmar sweating (1: dry; 2: mild; 3: moderate; 4: complete recurrence), compensatory sweating (1: no compensatory sweating; 2: occasional mild sweating; 3: frequent but not troublesome sweating, 4: frequent and troublesome sweating that interferes with daily activities), satisfaction (1~5, 1: dissatisfied and 5: very satisfied)., and any other complications.

Results: Ninety-two patients (31.8%) responded to the postal questionnaire. Of the 92 patients, 54 underwent cutting of the sympathetic chain at T3 (cutting group) and 38 underwent clamping of the sympathetic chain at T3 (clamping group).The incidence of postoperative compensatory sweating was significantly higher in the cutting group than in the clamping group (96.2% and 84.2%, respectively), and postoperative compensatory sweating was significantly more severe in the cutting group (3.3 ± 0.8) than in the clamping group (2.7 ± 1.0). The degree of postoperative palmar sweating was significantly lower in the cutting group (1.8 ± 0.8) than in the clamping group (2.3 ± 0.9). No significant difference in the average degree of patient satisfaction was observed between the cutting (2.0 ± 1.0) and clamping groups (2.2 ± 1.0). The degree of postoperative palmar sweating was inversely correlated with the degree of patient satisfaction (R =-0.26). A significant inverse correlation was similarly obtained between the severity of postoperative compensatory sweating and the degree of patient satisfaction (R =-0.36).

Conclusions: Sympathotomy by clamping at T3 was less effective in reducing the primary symptom of postoperative palmar sweating, but induced less compensatory sweating than did sympathotomy by cutting at T3. However, both methods were similar with regard to patient satisfaction.

Mechanism and assessment of the mental sweating

Satoshi Iwase

Department of Physiology, Aichi Medical University

Human sweating includes mental and thermal sweating, which bears several definitions, however, here we define the mental sweating as “sweating induced by afferent stress input through neural transmission,” and the thermal sweating as “sweating induced by afferent input through convectional transmission. Neural transmission arises at thermal receptors of the skin, and is transmitted through peripheral nerve → spinal cord → thalamus → cerebral cortex, and the individual is provoked thermal sensation, then the signal is sent to the hypothalamus. In contrast, convectional transmission means that heated or cooled blood circulates to the hypothalamus and stimulates the warm neuron in the hypothalamus, which conducts the warm feeling. The biggest difference between the neural and the convectional transmission is the chronological course. The simultaneous measurements with skin sympathetic nerve activity (SSNA) by microneurography, sweat rate by the ventilated capsule method, laser Doppler skin blood flow, skin temperature, and the core temperature (tympanic temperature) revealed that the neural transmission takes >1 min, whereas convectional transmission necessitates ~10 min, suggesting that the convectional transmission takes time. In other words, since convectional transmission takes too much time by feedback mechanism, humans uses neural transmission in order to respond to the environmental change immediately by feedforward mechanism. Therefore, humans have obtained “mental sweating mechanism” in the evolutional process for the quick response to the environmental change. This thermoregulatory system using sweating for the body cooling is observed only in the higher primates, and this is phylogenically higher mechanism. We have recorded the SSNA following cognitive or somatosensory stimulations, and analyzed the relationship between cognitive evoked potentials (P300) and sweating response, as well as the somatosensory evoked potentials (N140) and vasoconstrictive response. As the result, we found significant relationship between them respectively. This finding suggests that mental sweating associates cognitive function, which is phylogenically high level cerebral activity, and that sweating is effective and efficient thermoregulatory function using high level feedforward system.

The origin of this mental sweating is supposedly at the amygdala, and the function of medial prefrontal cortex suppressing the amygdala determines the degree of mental sweating. In the present talk, these mechanism will be described using electrophysiological methods including dipole tracing or functional MRI.






 

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