Video-assisted thoracic sympathectomy: literature review

1 Therezinha de Jesus Maternity Hospital, Service of Thoracic Surgery, Juiz de Fora, MG, Brazil. 2 Monte Sinai Hospital, Service of Thoracic Surgery, Juiz de Fora, MG, Brazil. 3 Faculty of Medical and Health Sciences of Juiz de Fora, Curse of Medicine, Juiz de Fora, MG, Brazil. 4 Monte Sinai Hospital, Service of Surgery, Juiz de Fora, MG, Brazil. Nicolini Video-assisted thoracic sympathectomy: literature review. 2 Rev Col Bras Cir 46(2):e2157 The objective of this study is to evaluate the current state of the art as to postoperative quality of life, surgery time and the complications of video-assisted sympathectomy.


INTRODUCTION
P rimary or essential hyperhidrosis is a disorder characterized by excessive and uncontrollable sweating, in the absence of a discernible cause.
It is a disease linked to emotional stress or psychological factors, which affects preferably the axillae, palms of the hands, soles of the feet and face.It is estimated that its incidence is 0.6% to 1% of the population, occurring more frequently in young patients.In 2004, in the United States, there were 150,000 people with hyperhidrosis (2.9% of the studied population), 51% being axillary, 25% palmar, and 20% facial.Of these patients, 38% required surgical treatment.While axillar and sole sweating cause discomfort in most cases, palmar hyperhidrosis causes social professionals, and often psychological problems 1 .
Conventional treatments for this condition do not guarantee satisfactory results, making surgical procedures necessary.
A treatment option is based on the removal of the eccrine and apocrine glands from the axillary region.Several techniques were proposed, all of them with a high rate of complications.In contrast, endoscopic surgery is less invasive and guarantees lower complications rates, thus being an excellent treatment indication 2 .Therefore, thoracoscopic surgical clipping (VATS) of the sympathetic branch has become an approach for the treatment of hyperhidrosis when conservative treatment has failed.Some of the advantages of endoscopic surgery that have been continuously recognized are the lower intensity of postoperative pain, the shorter hospital stay, the earlier return to normal activities and better esthetic results.However, it is associated with potentially relevant complications, such as postoperative compensatory sweating and Rev Col Bras Cir 46 (2):e2157 The objective of this study is to evaluate the current state of the art as to postoperative quality of life, surgery time and the complications of video-assisted sympathectomy.

METHOD
We performed a bibliographic search in the PubMed database, on January 2019, and selected articles from 2005 to 2019, written in English or in Portuguese, using the following terms: "sympathectomy", "hyperhidrosis", "quality of Life" and "video-assisted thoracoscopic" associated with their variations, in accordance with MeSH.
We found 58 items for reading the summary.We included all original articles with observational design, carried out in humans, whose main theme was sympathectomy performed by video-thoracoscopy for the treatment of hyperhidrosis.Among those, we selected articles that evaluated patients' quality of life after surgery, those studying postoperative complications, or those which indirectly addressed such aspects.We excluded articles that analyzed techniques used for surgery that did not address the quality of life or postoperative complications.After reading the abstracts, we selected 30 articles that met the criteria initially proposed for full reading.
After surgery, 11 considered it excellent, three, very good, and one, good.This situation demonstrates that sympathectomy may not be effective and reoperation may be indicated 6 .The mean postoperative follow-up period was 12.5 months 15 .After surgery, the hands and axillae of all patients were dry and warm.Sixteen (12%) patients in the one-stage group and 15 (11%) patients in the two-stage one suffered mild to moderate pain.
Compensatory hyperhidrosis occurred in 25 (19%)   patients in the one-stage group and in six (4%) of the two-stage one.This allows to consider that the two-stage approach could render lower probability of development of compensatory hyperhidrosis than the one-stage 15 .
Another study, with 120 patients with primary palmar hyperhidrosis, randomly divided subjects into two groups, electrocautery hook group (60 patients) and titanium clip group (60 patients).
All patients underwent sympathetic block at the T4 level.The postoperative follow-up period was two months and all patients were cured.It concluded that the majority of patients show a remarkable improvement in quality of life.However, there was no significant difference between groups 16 .trocar (Group C).One year after the procedure, there was no significant difference between T2-T4 and T3-T4 sympathectomy in terms of postoperative palmar anhidrosis or onset of compensatory hyperhidrosis 18 .

According to
Using thinner trocars (2-5mm) resulted in decreased postoperative intercostal pain and better cosmetic results, with higher levels of patient satisfaction.
Improvement in the quality of life of all patients has been reported even in the case of relapse or onset of compensatory hyperhidrosis 18 .
According Compensatory hyperhidrosis is the main and undesirable side effect that appears over time and is not related to the extent of sympathectomy.
Excessive dryness is reported by some patients, with no improvement over time.However, the degree of postoperative satisfaction is high, but decreases over time due to the appearance of recurrence and side effects.The efficacy and absence of compensatory sweating determine an excellent quality of life 23 .
Thus, it is clear that CH is a common situation in patients who undergo sympathectomy, and it is imperative that they are aware of this.

Resection level and results
The studies in question converge to the conclusion that the T4 level resection is a good treatment option, with effective success rates, especially in relation to the axillary and upper limb hyperhidrosis, since it features smaller compensatory sweating rates, and when present, it is milder.This allows quality of life to be guaranteed for longer.Regardless of the resection level, however, the increase in QoL is substantial [24][25][26][27][28][29][30] (Table 2).emphysema that resolved within 24-48 hours.One reported major pain for 24 hours, and another, pain in the puncture site that improved with common analgesic until disappearing within three months 12 .
Several other studies have reported no postoperative complications 8,20 .

Mean surgical time
One of the benefits of video-assisted surgery is its shorter operative time and hospital stay, which has been observed in several works.Four studies verified the time elapsed to perform the surgical procedure, and two evaluated the length of hospital stay.In the first, bilateral sympathectomy was performed with a single portal, the mean operative time being 38 minutes.Mean time of hospital stay was 1.1 days 7 .In the second, the mean operative time was 47 minutes for bilateral sympathectomy.The mean hospital stay was 1.15 days 20 .In the third, the mean operative time was 38 minutes in the one-stage group and 39 minutes in the two-stage one, since this study assessed the difference between the performance of unilateral, two-stages sympathectomy and the bilateral, one-stage approach 15 .In the fourth, the mean operative time for each side was 15 minutes for T3-T4 sympathectomy and 28 minutes for T2-T4 sympathectomy 18 .In another study, mean postoperative stay was 1.1 days 22 .These evidences demonstrate that the operative time is short for the endoscopic surgery, varying according to the procedure of choice, and the average hospital stay does not exceed two days.

CONCLUSIONS
From the analysis of several studies, we verified the importance of the level of sympathetic et al. evaluated the difference between unilateral sympathectomy performed in two surgical times compared with bilateral one in a single surgical time.For this, they recruited 270 patients with severe palmar and/or axillary hyperhidrosis.One hundred and thirty patients underwent one-stage, bilateral, single-port, video-assisted thoracoscopic sympathectomy (one-stage group), and 140, twostage, unilateral, video-assisted sympathectomy thoracoscopic, with an average interval of four months between procedures (two-stage group).
Garcia Franco et al., patients with hyperhidrosis obtained best results with surgery as compared to patients undergoing radiofrequency sympathicolysis in terms of efficiency and quality of life, despite a significant improvement in quality of life observed in patients treated with radiofrequency 17 .Patients with facial flushing achieved good results with surgical procedures, and not so satisfactory results with radiofrequency ablation, resulting in significant differences in treatment efficacy and quality of life.They concluded that patients with facial flushing treated with radiofrequency procedures did not show improvement in quality of life after the intervention.The results support the view of the surgical sympathectomy as the gold standard treatment for severe cases of hyperhidrosis and facial flushing, and radiofrequency sympathicolysis as a second option for patients with hyperhidrosis.The study of Scognamillo et al. aimed to evaluate and compare the immediate and longterm results of T2-T4 with T3-T4 thoracoscopic sympathectomy for the treatment of palmar and axillary hyperhidrosis.Twenty-four patients underwent T2-T4 sympathectomy with a 5-10mm trocar (Group A), 43 T2-T4 a with 2-5mm trocar (Group B), 15 T3-T4 sympathectomy with a 5-10mm trocar, and six T3-T4 sympathectomy with a 2-5mm

4 .A
longitudinal follow-up study on cardiac vagal activity investigated the possibility of sympathectomy at the T4, T5 and T6 levels result in cardiac performance alterations.Patients undergoing the procedure were evaluated for the cardiac vagal activity by means of resting heart rate and the cardiac vagal index in the preoperative period, one month after surgery and four years postoperatively.There were changes in the first month, with a predominance of the action of the parasympathetic branch that reverted after four years, suggesting a physiological adaptation of the organism 13 .Concerning adolescents and children, a study of 25 patients showed that the rate of postoperative complications was 20%, all being transient.Three patients had subcutaneous

Table 1 .
Evaluation of quality of life after sympathectomy.

Table 2 .
Evaluation of the sympathectomy resection level.