LETTERS TO THE EDITOR "Thoracoscopic Sympathectomy"
Resource
SURGICAL LAPAROSCOPY ENDOSCOPY & PERCUTANEOUS TECHNIQUES v.11 n.2 pp. 152-153
Journal
SURGICAL LAPAROSCOPY ENDOSCOPY & PERCUTANEOUS TECHNIQUES
Journal Volume
v.11
Journal Issue
n.2
Pages
p-p
Date Issued
2001
Date
2001
Author(s)
KAO, MING-CHIEN
Abstract
I read with interest the article “Thoracoscopic Sympathectomy”(1), in which the authors confirm the value and usefulness of several important techniques of endoscopic thoracic sympathectomy. However, these techniques have been reported in our previous articles (2,3), including: 1) the use of one port with a 10-mm operative thoracoscope for ablation of the sympathetic trunk; 2) placement of the patient in a semi-Fowler position with both arms abducted to facilitate bilateral sympathectomy in one stage ; 3) electrocauterization of the sympathetic segment with a cautery instead of with mechanical resection, which is time- consuming and has a potential risk for injury to the intercostal vessels and nerves; and 4) the use of a small rubber tube to drain residual air out of the thoracic cavity before closing the skin wound to ensure full expansion of the lung. Unfortunately, our reported techniques were not cited when describing the treatment of a great number of cases of palmar hyperhidrosis with endoscopic thoracic sympathectomy. I would further emphasize several important points about this procedure. To obtain definite relief of palmar hyperhidrosis, we first advocated the use of intraoperative monitoring of palmar skin temperature to aid in confirming correct sympathectomy (4). We found that en bloc ablation of the T2 segment (containing a major part of the T2 ganglion and the adjacent nerve fibers overlying the second rib neck) as confirmed by significant elevation of palmar skin temperature (of approximately 2–3 °C) can guarantee definite and long-lasting therapeutic results. Therefore, this level of sympathectomy could be considered an adequate and standard extent for palmar hyperhidrosis (3, 4) . Regarding craniofacial hyperhidrosis, in 1991 we were the first to report the use of the endoscopic transthoracic approach to ablate the sympathetic T2 segment to manage this disease, and obtained satisfactory results (5). The patients usually have a cold, damp face, which becomes flushed when they are under emotional stress, particularly in a hot and humid environment. This should be differentiated from postmenopausal hot flushing (6). The incidence of compensatory hyperhidrosis (CH) varies with geographic location, working environmental temperatures and humidity, and the season in which it is surveyed; therefore, it varies greatly from 30% to 85%. The mechanism of CH remains unclear. The severity of CH is related to the extent of sympathectomy; that is, the more extensive the sympathectomy, the more serious the CH. Based on neurophysiology, a reversible technique, advocated by Lin et al. and mentioned in the article (1), was unreliable and without a rational basis. When the clip is not tight enough to completely interrupt the sympathetic trunk, palmar hyperhidrosis may be relieved for a short period, but will inevitably relapse very early. When the clip is tight enough to crush and induce regional necrosis of the sympathetic trunk, its final effect does not differ from that of mechanical cutting or electrocauterization of the target sympathetic trunk. Furthermore, the removal of a postoperative tightly adhering clip from the sympathetic trunk to relieve the complications of compensatory CH is not only ineffective but also technically time-consuming. It is also interesting to note that incomplete or inadequate removal of the target trunk will result in early recurrence of palmar hyperhidrosis, but the complications of CH will persist. Reoperating with adequate ablation of the target trunk can cure the recurrence of palmar hyperhidrosis and alleviate the complications of CH. We believe that the above statements will be useful for those performing thoracoscopic sympathectomy.
Type
journal article