Hyperhidrosis Surgical Management & Consequences Gamal Marey - - PowerPoint PPT Presentation

▶
hyperhidrosis surgical management amp consequences
SMART_READER_LITE
LIVE PREVIEW

Hyperhidrosis Surgical Management & Consequences Gamal Marey - - PowerPoint PPT Presentation

Sep 07, 2023 90 likes •391 views

www.downstatesurgery.org Hyperhidrosis Surgical Management & Consequences Gamal Marey SUNY Downstate Medical Center 8/21/2014 www.downstatesurgery.org History 25 y/o female, with PMH significant for long standing hyperhidrosis of

slide-1
SLIDE 1

Hyperhidrosis Surgical Management & Consequences

Gamal Marey SUNY Downstate Medical Center 8/21/2014

www.downstatesurgery.org

slide-2
SLIDE 2

History

  • 25 y/o female, with PMH significant for long standing

hyperhidrosis of both palms and soles, presented for elective B/L Thoracoscopic Sympathectomy after failed medical management x5 years.

  • PMH- Hyperhidrosis, HTN
  • PSH- left breast cyst excision
  • Meds- HCTZ
  • Allergy- NKDA
  • SH- No ETOH , smokes 2cig./day
  • Allergy- NKDA
  • FH- Uncle with hyperhidrosis

www.downstatesurgery.org

slide-3
SLIDE 3

Physical Exam

  • BP 134/87 HR 84 T 98.1 O2 100
  • AAOx3, NAD
  • + Profuse sweeting from both palms > face,

axillae and soles

www.downstatesurgery.org

slide-4
SLIDE 4

S/P T3 B/L Sympathectomy

www.downstatesurgery.org

slide-5
SLIDE 5

Overview

  • Anatomy
  • Epidemiology
  • Pathophysiology
  • Diagnostic Criteria
  • Treatment options
  • Consequences
  • Conclusions

www.downstatesurgery.org

slide-6
SLIDE 6

www.downstatesurgery.org

slide-7
SLIDE 7

www.downstatesurgery.org

slide-8
SLIDE 8

What is Hyperhidrosis?

  • Pathological condition of excessive sweat

production greater than physiologically needed for thermoregulation.

  • 'silent handicap'

University of Miami Cosmetic Center, 2007

www.downstatesurgery.org

slide-9
SLIDE 9

Types

  • Primary focal Hyperhidrosis- chronic idiopathic

conditions

  • Secondary (Generalized)- secondary to excessive

heat or medical conditions (spinal cord injury, respiratory or heart failure, drugs, alcohol abuse, infectious, endocrine & malignancy).

www.downstatesurgery.org

slide-10
SLIDE 10

Epidemiology of primary focal Hyperhydrosis

  • 1 : 3 percent of the population
  • More common in hot climate
  • Affects Both sexes equally
  • Onset is mostly at puberty or early adulthood
  • Predilection sites: axillae, palms, soles, face
  • 70% undiagnosed
  • Peaks in early adulthood
  • 50% of the patients have a family history
  • Affect patients both socially and functionally
  • It is not considered a psychological disorder.

www.downstatesurgery.org

slide-11
SLIDE 11

Pathophysiology

  • Three types of sweat glands (2-5 million sweat glands)
  • Eccrine-

 Responsible for hyperhidrosis  located throughout the body (face, palm, sole & axilla)  Primary function thermoregulation  Activated by emotional and thermal stimuli  Secrets clear, odorless sweat  Innervated by the postganglionic sympathetic nerve fibers  Acetylcholine as the primary neurotransmitter.

  • Apocrine-

 Androgen dependent, Inactive until puberty ( Axilla, genital areas)  Produce viscous fluid with characteristic body odor sweat  Unclear function in humans/some role in olfactory communication  Catecholamines as the primary neurotransmitter.

  • Apoeccrine-

 Found in Axilla, only adults, unclear function

www.downstatesurgery.org

slide-12
SLIDE 12

Pathophysiology

  • Thermal sweating is controlled by hypothalmus

(exercice, hormones, Temp. change, stress)

  • Emotional sweating is regulated by the cerebral

cortex

  • the cause of hyperhidrosis appears to be an

abnormal or exaggerated central response to normal heat and emotional stress. www.downstatesurgery.org

slide-13
SLIDE 13

Sympathetic innervation

Face T2-T4 Trunk T4-T12 Upper limbs T2 – T8 Lower limbs T10-T12

www.downstatesurgery.org

slide-14
SLIDE 14

Diagnosis of Primary Focal Hyperhidrosis

  • Focal, visible, excessive sweating of at least 6

months duration without apparent cause with at least 2 of the following characteristics: Bilateral and symmetric Impairs daily activities At least one episode per week Onset before age 25 Positive Family history Stops during sleep www.downstatesurgery.org

slide-15
SLIDE 15

Quality of Life: Primary Palmar Hyperhidrosis

100 patients, palmar, presenting for sympathectomy

Interference with daily task 95% Social embarrassment 90% Psychological difficulties 40%

Adar et al Ann Surg;186: 1977 34-41

www.downstatesurgery.org

slide-16
SLIDE 16

Pathogenesis of PFH

  • Exact cause is unknown
  • Familial or genetic?
  • Excessive Sympathetic Activity?

www.downstatesurgery.org

slide-17
SLIDE 17

Symptoms

  • Excessive sweating (palms, soles, and axillae)
  • Worse by heat or emotional stimuli
  • skin maceration and clothes staining
  • increased incidence of cutaneous disorders.
  • Dehydration
  • Associated with social and professional problems

(Fear of shaking hands, soiling of papers, etc..) www.downstatesurgery.org

slide-18
SLIDE 18

Treatment of PFH

  • Topical meds- antiperspirant (Aluminum chloride) 88%
  • effective. Topical anticholinergic (Glycopyrrolate,
  • xybutinin)
  • Iontophoresis- (palmar/planter), 83% effective
  • Systemic meds- Anticholinergic (Robinul) 21%

effective, SE- (xerostomia, mydriasis, blurry vision, Headache, Urinary retention). B-blockers, and benzodiazepines for emotional hyperhidrosis.

  • Botulinum Toxin- blocks the release of acetylcholine

from the presynaptic junction (lasts 6-7 mon.), 90% effective.

www.downstatesurgery.org

slide-19
SLIDE 19

Treatment of PFH

  • Local sweat gland resection- Used only for axillary

hyperhidrosis (subcut. Curettage, excision of skin conaining eccrine glands, suction curettage), 80-90% effective.

  • B/L Thoracoscopic Sympathectomy (ETS)- involves the

interruption of the upper thoracic sympathetic chain  T3 Ganglion- Craniofacial hyperhidrosis  T4 Ganglion- Palmar hyperhidrosis  T4 andT5 Ganglion- Axillary only or palmar, axillary and pedal hyperhidrosis

  • >95% success rate in palmar hyperhidrosis

www.downstatesurgery.org

slide-20
SLIDE 20

ETS Consequences

  • Hemo-pneumothorax– 1%
  • Atelectasis
  • Bradycardia
  • Intercostal neuralgia – 1%
  • Horner’s Syndrome – 1-3%
  • Compensatory Sweating – 60%

Stellate ganglion – fusion of C8 and T1, Innervates the face If Stellate ganglion is damaged, Horner’s Syndrome will occur. May be mistaken for T2 and T3. May receive electrical current from cautery of T2 and T3

www.downstatesurgery.org

slide-21
SLIDE 21

Endoscopic transthoracic sympathectomy: an efficient and safe method for the treatment of hyperhidrosis. Drott C, Göthberg G, Claes G J Am Acad Dermatol. 1995;33(1):78

  • A series of 850 patients with upper extremity

hyperhidrosis

  • Median follow-up of 31 months
  • 98 percent of patients reported satisfactory

results

  • only 2 percent developing recurrent symptoms.
  • Horner's syndrome occurred in 3 cases
  • Compensatory sweating, primarily of the trunk,
  • ccurred in 55 percent of patients, but only 2

percent considered this to be as bothersome www.downstatesurgery.org

slide-22
SLIDE 22

Endoscopic thoracic sympathectomy for primary hyperhidrosis of the upper

  • limbs. A critical analysis and long-term results of 480 operations.

Herbst F, Plas EG, Függer R, Fritsch A Ann Surg. 1994;220(1):86

  • Review of 480 sympathectomies
  • No major complications
  • Initially, 95.5 percent were satisfied with the results of

surgery.

  • After a mean follow-up of 14.6 years, 66.7 percent were

satisfied and 26.7 percent were partially satisfied

  • Recurrence rate of only 1.5 percent
  • Patients with axillary hyperhidrosis without palmar

involvement were the least satisfied.

  • Compensatory sweating, occurred in 67.4 percent of

patients, was the most frequently stated reasons for dissatisfaction.

www.downstatesurgery.org

slide-23
SLIDE 23

Treatment of palmar hyperhidrosis: T(4) level compared with T(3) and T(2).

Chang YT, Li HP, Lee JY, Lin PJ, Lin CC, Kao EL, Chou SH, Huang MF Ann Surg. 2007;246(2):330.

  • A retrospective review of 234 patients
  • palmar hyperhidrosis is most commonly

performed at a T2 or T3 level

  • Similar efficacy was seen with T4-level ETS
  • T4 level had less compensatory sweating than

those with higher sympathectomies

www.downstatesurgery.org

slide-24
SLIDE 24

Satisfaction and compensatory hyperhidrosis rates 5 years and longer after video-assisted thoracoscopic sympathotomy for hyperhidrosis

Ayesha S. Bryant, MD, MSPH, and Robert James Cerfolio, MD, FACS, FCCP J Thorac Cardiovasc Surg. 2014 Apr;147(4):1160-1163

  • Prospective cohort study, 173 patients (1999-2012)
  • 96 pts had very poor quality of life before surgery
  • No postop. Bradycardia or Horner's syndrome, 1 patient

required chest tube

  • CH- 77% I year, 37% 5 years (decreases signif. from 1-2 yrs)
  • 79% reported improvement in their quality of life at 1 year

after surgery, 85% 3 years, 89% 5 years.

  • CH significantly greater for R2/R3 vs R4/R5 sympathotomy ,

Multifocal hyperhidrosis on presentation, used oral anticholinergic meds. preoperatively and female

  • 6.2% regretted having the operation for CH

www.downstatesurgery.org

slide-25
SLIDE 25

Summary

  • Patients with PFH, can suffer significant psychological, social,

educational, and occupational consequences.

  • The severity and location of hyperhidrosis helps guide the

choice of therapies

  • the patient's goals in therapy should be understood, and the

side effects associated with each therapy should be carefully discussed.

  • surgery should be reserved for those with the most severe

manifestations and after other less invasive options have been exhausted.

www.downstatesurgery.org

slide-26
SLIDE 26
  • Conservative treatments has limited success rate
  • Endoscopic Thoracic Sympathectomy (ETS), is the
  • nly highly effective and definitive treatment for

PFH.

  • The higher the level of blockade on the chain, the

higher is the expected CH.

  • Despite the appearance of postoperative

complications, such as compensatory sweating, patient satisfaction is high and their quality of life improved. www.downstatesurgery.org

slide-27
SLIDE 27

Summary

www.downstatesurgery.org

slide-28
SLIDE 28

References

  • 1. Hornberger J, Grimes K, Naumann M, et al. Recognition, diagnosis, and treatment of primary focal
  • hyperhidrosis. J Am Acad Dermatol 2004; 51:274.
  • 2. Baumgartner FJ, Berlin S, Konecny J. Superiority of thoracoscopic sympathectomy over medical

management for the palmoplantar subset of severe hyperhidrosis. Ann Vasc Surg. 2009;23:1-7.

  • 3. Ambrogi V, Campione E, Mineo D, Paterno EJ, Pompeo E, Mineo TC. Bilateral thoracoscopic T2 to T3

sympathectomy versus botulinum injection in palmar hyperhidrosis. Ann Thorac Surg. 2009;88:238-45.

  • 4. Cerfolio RJ, De Campos JRM, Bryant AS, Connery CP, Miller DL, DeCampMM, et al. The expert

consensus document: The Society of Thoracic Surgeons Expert Consensus for the Surgical Treatment of

  • Hyperhidrosis. Ann Thorac Surg. 2011; 91:1642-8.
  • 5. Lyra RM, De Campos JRM, Kang DWW, Loureiro MP, Furian MB, Costa MG, et al. Guidelines for the

prevention, diagnosis and treatment of compensatory hyperhidrosis. J Bras Pneumol. 2008;34:967-77.

  • 6. Sugimura H, Spratt EH, Compeau CG, Kattail D, Shargall Y. Thoracoscopic sympathetic clipping for

hyperhidrosis: long-term results and reversibility. J Thorac Cardiovasc Surg. 2009;137:1370-6.

  • 7. Chwajol M, Barrenechea Ignacio J, Chakraborty S, Lesser JB, Connery CP, Perin NI. Impact of

compensatory hyperhidrosis on patient satisfaction after endoscopic thoracic sympathectomy.

  • Neurosurgery. 2009;64:511-8.
  • 8. De Campos JRM, Kauffman P, Werebe ED, Filho LO, Kisniek S, Wolosker N, et al. Quality of life, before

and after thoracic sympathectomy: report on 378 operated patients. Ann Thorac Surg. 2003;76:886-91.

www.downstatesurgery.org