While there was no opportunity to speak with Dr. Jose Ribas de Milanez de Campos at length, Cirugia de Torax did have a chance to talk briefly with the world-renown Brazilian thoracic surgeon about his presentation on VATS sympathetectomy for the treatment of hyperhidrosis. He is one of the foremost experts on hyperhidrosis and the treatment of this condition. (He, along with other thoracic surgery legends, Cefalio and McKenna helped draft the STS statement of the topic.)
Dr. Ribas reviewed the current literature as well as the most recent ATS Expert Consensus, and changes in international nomenclature for the ongoing research in the treatment of hyperhidrosis.
State of the evidence
At the 2009 American Thoracic Society expert consensus for surgical treatment of hyperhidrosis – a meta-analysis of the existing data was performed. Of the 1097 different papers, there were just 102 detailing clinical trials. Of these, only 12 studies met the criteria as randomized trials, and these studies were conducted by just three different groups of surgeons. Findings were based on this small pool of data.
Changes in nomenclature
Following the review of this data, several changes in surgical nomenclature were suggested to increase the clarity of data reporting among surgeons. One of the main points of confusion is the use of the ganglia level to report and describe procedures. This is problematic since multiple studies, including cadaveric studies, have shown that there are multiple anatomic variations in ganglia level. Also obese body habitus may obscure landmarks/ levels of ganglia in the fat tissue. Thus, the ATS now suggests that surgeons use “Rib Level” when reporting sympathectomy procedures. This is believed to allow greater precision and accuracy in data reporting.
Surgeons are also encouraged to classify surgical procedures as either sympathetomy, sympathiocomy or ramicotomy – mentioning the mechanism of sympathetic interruption; clipped versus cut, cauterised or otherwise removed. There is no clearly superior method but surgeons need to be sure that there is enough separation between the ends of the sympathetic chains. Dr. de Campos prefers dual port incisions over single port access for better visibility, and considers the harmonic scalpel much more precise.
The third major recommendation for surgeons performing sympathetectomies – is the recommended use of quality of life questionnaires for periodic follow-up with patients.
Treating hyperhidrosis
Level of sympathetic interruption should be related to patient’s primary symptomatology.
R2, R3 for patients with facial symptoms such as facial flushing.
R3 & R4 for patients with palmar symptoms.
R4 & R5 for patients with palmar and (severe) axillary sweating.
This is important because patients report greater satisfaction, less regrets and less side effects with the lower level blockages (R4 versus R2). Due to the inexactness of reports and poor follow-up, it is hard to know the incidence of compensatory hyperhidrosis (or compensatory sweating of lower extremities). Literature has reported the incidence at 3% – 98% of patients, making it difficult to quantify.
Patients who have sympathetic interruption of both R2 & R3 increases the risks of compensatory hyperhidrosis and Horner’s syndrome. This compensatory sweating is also more severe in warmer climates.
Best Candidates for the procedure
The best candidates for the procedure are patients who developed symptoms at an early age. Palmar symptoms often begin in young children (including toddlers). Axillary symptoms usually start during adolescence, with craniofacial symptoms beginning in young adulthood.
Surgery is most effective in younger patients (under the age of 25). Patients also need to be of normal weight for the best results with a BMI of 25 or less*. This is important because the greater the weight (or body mass index), the higher the incidence of compensatory sweating – which will prevent effective surgical treatment.
Common complications
The most common complications are compensatory sweating, and Horner’s syndrome. This occurs more frequently with higher level surgeries.
When to have surgery
Patients should consider surgery only after exhausting other treatments – as the expert consensus states sympathectomy should be considered a procedure of “last resort.”
However, oxybutynin treatment has shown promise for the treatment of hyperhidrosis. After 45 to 90 days of oxybutynin treatment, 80% of patients will respond favorably with noticeable improvement in symptoms. Surgery should be reserved for refractory cases.
*BMI of 28 or less in the United States, according to national guidelines.
References
Includes a limited list of publications by Dr. Rivas de Milanez de Campos on this topic.
ATS Expert Consensus for the Surgical Treatment of Hyperhidrosis powerpoint presentation – October 6, 2012, XVI Congreso Boliviana de Cirugia Cardiaca, Toracica y Vascular, Santa Cruz de la Sierra, Bolivia.
M.A. Callejas, R. Grimalt, E. Cladellas (2010). Hyperhidrosis update. Dermo-Sifiliográficas (English Edition), Volume 101, Issue 2, March–April 2010, Pages 110-118.
Cameron AE, Connery C, De Campos JR, Hashmonai M, Licht PB, Schick CH, Bischof G; International Society of Symapathetic Surgery. Percutaneous chemical dorsal -sympathectomy for hyperhidrosis. Minim Invasive Neurosurg. 2011 Oct;54(5-6):290. Epub 2012 Jan 25 [letter].
Cerfolio RJ, De Campos JR, Bryant AS, Connery CP, Miller DL, DeCamp MM, McKenna RJ, Krasna MJ. (2011). The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg. 2011 May;91(5):1642-8. Review.
De Campos JR, Hashmonai M, Licht PB, Schick CH, Bischof G, Cameron AE, Connery CP. (2012). Treatment options for primary hyperhidrosis. Am J Clin Dermatol. 2012 Apr 1;13(2):139. [comment].
de Campos JR, Kauffman P, Werebe Ede C, Andrade Filho LO, Kusniek S, Wolosker N, Jatene FB. (2003). Quality of life, before and after thoracic sympathectomy: report on 378 operated patients. Ann Thorac Surg. 2003 Sep;76(3):886-91. [full-text not available.]
de Campos JR, Wolosker N, Takeda FR, Kauffman P, Kuzniec S, Jatene FB, de Oliveira SA. (2005). The body mass index and level of resection: predictive factors for compensatory sweating after sympathectomy. Clin Auton Res. 2005 Apr;15(2):116-20
de Campos JR, Wolosker N, Yazbek G, Munia MA, Kauffman P, Puech-Leao P, Jatene FB. (2010). Comparison of pain severity following video-assisted thoracoscopic sympathectomy: electric versus harmonic scalpels. Interact Cardiovasc Thorac Surg. 2010 Jun;10(6):919-22. Epub 2010 Mar 16.
de Lima AG, de Campos JR, Jatene FB. (2011). Seasonal influence of the surgical outcome after thoracic sympathectomy for hyperhidrosis. Clin Auton Res. 2011 Jun;21(3):169-70
de Lima AG, Das-Neves-Pereira JC, de Campos JR, Jatene FB. (2011). Factors affecting long-term satisfaction after thoracic sympathectomy for palmar and plantar hyperhidrosis. Is the sudomotor reflex the only villain? Interact Cardiovasc Thorac Surg. 2011 Apr;12(4):554-7. Epub 2010 Dec 20.
Hashmonai M, Licht PB, Schick CH, Bishof G, Cameron AE, Connery CP, De Campos JR; International Society of Sympathetic Surgery. (1999). Late results of endoscopic thoracic sympathectomy for hyperhidrosis and facial blushing. Br J Surg. 2012 May;99(5):738; author reply 738-9
Ishy A, de Campos JR, Wolosker N, Kauffman P, Tedde ML, Chiavoni CR, Jatene FB. (2011). Objective evaluation of patients with palmar hyperhidrosis submitted to two levels of sympathectomy: T3 and T4. Interact Cardiovasc Thorac Surg. 2011 Apr;12(4):545-8. Epub 2011 Jan 1.
Kauffman P, Wolosker N, de Campos JR, Yazbek G, Jatene FB. (2010). Azygos lobe: a difficulty in video-assisted thoracic sympathectomy. Ann Thorac Surg. 2010 Jun;89(6):e57-9.
Loureiro Mde P, de Campos JR, Kauffman P, Jatene FB, Weigmann S, Fontana A. (2008). Endoscopic lumbar sympathectomy for women: effect on compensatory sweat. Clinics (Sao Paulo). 2008 Apr;63(2):189-96
Martins Rua JF, Jatene FB, de Campos JR, Monteiro R, Tedde ML, Samano MN, Bernardo WM, Das-Neves-Pereira JC. (2009). Robotic versus human camera holding in video-assisted thoracic sympathectomy: a single blind randomized trial of efficacy and safety. Interact Cardiovasc Thorac Surg. 2009 Feb;8(2):195-9. Epub 2008 Nov 28.
Munia MA, Wolosker N, Kauffman P, de Campos JR, Puech-Leão P. (2007). A randomized trial of T3-T4 versus T4 sympathectomy for isolated axillary hyperhidrosis. J Vasc Surg. 2007 Jan;45(1):130-3.
Munia MA, Wolosker N, Kaufmann P, de Campos JR, Puech-Leão P. (2008). Sustained benefit lasting one year from T4 instead of T3-T4 sympathectomy for isolated axillary hyperhidrosis. Clinics (Sao Paulo). 2008 Dec;63(6):771-4.
Neves S, Uchoa PC, Wolosker N, Munia MA, Kauffman P, de Campos JR, Puech-Leão P. (2012). Long-term comparison of video-assisted thoracic sympathectomy and clinical observation for the treatment of palmar hyperhidrosis in children younger than 14. Pediatr Dermatol. 2012 Sep;29(5):575-9.
Westphal FL, de Campos JR, Ribas J, de Lima LC, Lima Netto JC, da Silva MS, Westphal DC. (2009). Skin depigmentation: could it be a complication caused by thoracic sympathectomy? Ann Thorac Surg. 2009 Oct;88(4):e42-3. case reports.
Wolosker N, de Campos JR, Kauffman P, de Oliveira LA, Munia MA, Jatene FB. (2012). Evaluation of quality of life over time among 453 patients with hyperhidrosis submitted to endoscopic thoracic sympathectomy. J Vasc Surg. 2012 Jan;55(1):154-6
Wolosker N, de Campos JR, Kauffman P, Neves S, Munia MA, BiscegliJatene F, Puech-Leão P. (2011). The use of oxybutynin for treating axillary hyperhidrosis. Ann Vasc Surg. 2011 Nov;25(8):1057-62.
Wolosker N, de Campos JR, Kauffman P, Puech-Leão P (2012). A randomized placebo-controlled trial of oxybutynin for the initial treatment of palmar and axillary hyperhidrosis . Journal of Vascular Surgery, Volume 55, Issue 6, June 2012, Pages 1696-1700.
Wolosker N, Yazbek G, de Campos JR, Munia MA, Kauffman P, Jatene FB, Puech-Leao P. (2010). Quality of life before surgery is a predictive factor for satisfaction among patients undergoing sympathectomy to treat hyperhidrosis. J Vasc Surg. 2010 May;51(5):1190-4.
Yazbek G, Wolosker N, de Campos JR, Kauffman P, Ishy A, Puech-Leão P. (2005). Palmar hyperhidrosis–which is the best level of denervation using video-assisted thoracoscopic sympathectomy: T2 or T3 ganglion? J Vasc Surg. 2005 Aug;42(2):281-5.
Wolosker N, de Campos JR, Kauffman P, Neves S, Yazbek G, Jatene FB, Puech-Leão P. (2011). An alternative to treat palmar hyperhidrosis: use of oxybutynin. Clin Auton Res. 2011 Dec;21(6):389-93.
Wolosker N, Yazbek G, Ishy A, de Campos JR, Kauffman P, Puech-Leão P. (2008). Is sympathectomy at T4 level better than at T3 level for treating palmar hyperhidrosis? J Laparoendosc Adv Surg Tech A. 2008 Feb;18(1):102-6. [full-text not available.]
For additional information on this topic:
Nauman, M., Davidson, J. R. T. & Glaser, D. (2002). Hyperhidrosis: Current Understanding, Current Therapy. Medscape. [Registration required for Medscape]. Click article title for pdf version. While this article is dated back to 2002, it gives a good overview of hyperhidrosis for people who are unfamiliar with this condition.
Thoracic Surgery 