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Print version ISSN 0034-7094
On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.55 no.3 Campinas May/June 2005
Thoracoscopic sympathectomy to treat palmar hyperhydrosis: anesthetic implications*
Simpatectomia por videotoracoscopia en el tratamiento de la hiperhidrosis palmar: implicaciones anestésicas
Monia Di Lara Dias, M.D.I; Artur Antônio Burlamaque, M.D.II; Airton Bagatini, TSA, M.D.III; Fábio Amaral Ribas, TSA, M.D.III; Cláudio Roberto Gomes, TSA, M.D.IV
IAnestesiologista do SANE
IIResponsável pelo Serviço de Anestesiologia Torácica do Pavilhão Pereira Filho de Porto Alegre
IIICo-responsável pelo CET-SBA do SANE
IVInstrutor do CET-SBA do SANE
BACKGROUND AND OBJECTIVES: Primary hyperhydrosis
is a disorder characterized by excessive diffuse or localized sweating. There
are several noninvasive therapeutic methods which in general do not solve the
problem generating even more anxiety, and time and money wasting for hyperhydrosis
patients. Partial thoracic sympathetic chain resection is indicated for palmar
hyperhydrosis and may be performed by thoracoscopic surgery with good results
and few complications. This review aimed at discussing possible anesthetic techniques
for this procedure, as well as possible complications and their management.
CONTENTS: It is estimated that the incidence of primary hyperhydrosis varies from 0.6% to 1%, being more frequent in young patients. While in most cases axillary and plantar sweating causes discomfort only, excessive palmar sweating causes social, professional and psychological problems. Thoracoscopic sympathectomy has been performed in several hospitals and is increasing in number. Unless there are specific counterindications, bilateral sympathectomy is performed under general anesthesia through a double or single lumen catheter, with or without intrapleural carbon dioxide inflation. Major postoperative cares are early pneumothorax or residual hemothorax diagnosis, nausea and vomiting prevention and postoperative pain control.
CONCLUSIONS: Intrathoracic sympathectomy is an effective method to treat palmar hyperhydrosis and the number of procedures is increasing. The introduction of thoracoscopy has improved the technique, has decreased morbidity, surgery length and hospital stay. Adequate anesthetic management, continuous monitoring and available techniques allow the procedure to be safely performed or that approaches are changed according to clinical observations and patients' responses to dynamic changes induced by surgery and drugs. It is up to the anesthesiology to make judicious and sensible use of available techniques to assure safe procedure and fast recovery with the least possible morbidity.
Key words: SURGERY, Thoracic: sympathectomty, thoracoscopy; TREATMENT: palmar hyperhydrosis
JUSTIFICATIVA Y OBJETIVOS: La hiperhidrosis
primaria es un desorden caracterizado por sudoresis excesiva difusa o localizada.
Existen innúmeros métodos terapéuticos no invasivos que
en general no solucionan el problema, generando más ansiedad, pérdida
monetaria y de tiempo para los pacientes que sufren con hiperhidrosis. La resección
de parte de la cadena simpática torácica está indicada
en casos de hiperhidrosis palmar y puede ser hecha a través de cirugía
toracoscópica con buenos resultados y pocas complicaciones. La finalidad
de esta revisión es discutir las posibles técnicas anestésicas
para este procedimiento, bien como posibles complicaciones y manoseo.
CONTENIDO: Se estima que la incidencia de hiperhidrosis primaria sea del 0,6% a 1%, ocurriendo con mayor frecuencia en pacientes jóvenes. Mientras la sudoresis axilar y plantar, en la mayoría de los casos, causa apenas desaliento, el exceso de sudor en las manos causa problemas sociales, profesionales y psicológicos. La simpatectomia por videotoracoscopia ha sido realizada en varios hospitales y es creciente su número. Sin que ocurran contraindicaciones específicas, la simpatectomia es realizada bilateralmente bajo anestesia general a través de un tubo de doble lumen o tubo simple con o sin asociación de insuflación de dióxido de carbono intrapleural. Las principales atenciones postoperatorias son el diagnóstico precoz de neumotórax o hemotórax residual, prevención de náuseas y vómitos y control del dolor postoperatorio.
CONCLUSIONES: La simpatectomia torácica es un método eficaz para el tratamiento de la hiperhidrosis palmar y es creciente el número de procedimientos. La introducción de la videotoracoscopia mejoró la técnica, redujo la morbidad, el tiempo quirúrgico y el tiempo de permanencia hospitalaria. El adecuado manoseo anestésico, monitorización continuada y las técnicas a disposición permiten que el procedimiento sea realizado con seguridad o se modifiquen las conductas de acuerdo con las observaciones clínicas y las respuestas del paciente a las alteraciones dinámicas consecuentes de la cirugía y terapéutica farmacológica. Sería entonces, deber del anestesiologista disponer con criterio y buen sentido de las alternativas disponibles para asegurar al paciente un procedimiento seguro, una recuperación rápida con la menor morbidad posible.
Stellate ganglion and partial cervical or thoracic sympathetic chain resection or neurolysis is indicated for some cases of complex regional painful syndrome, hyperhydrosis or ischemic upper limb vascular events. As opposed to highly traumatic conventional approach (cervicotomy or axillary thoracotomy) this procedure may be performed by thoracoscopy. Advantages of endoscopic surgeries are being increasingly recognized, among them less postoperative pain, shorter hospital stay, earlier return to normal activities and jobs, with better cosmetic results 1.
Thoracoscopic surgery differs from other endoscopic procedures for involving pulmonary collapse ipsilateral to surgical procedure to offer adequate exposure and minimize risks of inadvertent pulmonary injury. There are two described techniques to achieve pulmonary collapse for thoracoscopic sympathectomy: single lung ventilation or pneumothorax with intrapleural carbon dioxide inflation. None is risk-free and both are related to major respiratory and hemodynamic changes.
This review on thoracoscopic sympathectomy to treat isolated hyperhydrosis (palmar, axillary and plantar) emphasizes major anesthetic considerations and techniques related to this procedure.
Excessive sweat production by sudoriferous glands is called hyperhydrosis and may be present in two clinical forms - localized (axillary, palmar and plantar) and generalized when affecting the whole skin 2. Its estimated incidence varies from 0.6% to 1% being more frequent in young patients without significant difference between genders. While axillary and plantar sweating in most cases causes discomfort only, excessive palmar sweating causes social professional and very often psychological problems 3,4.
There are several alternatives to treat hyperhydrosis, however failure rate is very high and none is complication-free. Therapeutics with antiperspirants, drugs, biofeedback, iontophoresis, percutaneous block with phenol and more recently subcutaneous botulinun toxin A injections are described 2,5,6. In most studies, success has been transient or was observed in very few cases 2,7. Studies involving isolated hyperhydrosis treatment with surgical ablation of upper chest sympathetic chain have been associated to excellent results.
With such evidences, surgeries have been performed to treat hyperhydrosis in cases where conservative methods were depleted. It is currently considered first choice treatment 8. The introduction of sympathetic chain electrocauterization has simplified the procedure with increased interest for palmar hyperhydrosis and its surgical treatment 9. In a study with 602 patients, excellent results were shown with symptoms recurrence in 0.8% of cases. One Horner syndrome case and 0.4% and 0.15% incidence of pneumothorax and hemothorax, respectively, were reported. Postoperative pain evaluated by visual scale was mild 9.
Since thoracic sympathetic chain is relatively inaccessible, sympathectomy was traditionally performed by thoracotomy. The access may be supraclavicular, axillary or posterior thoracic. However, none of these procedures is simple and all are at risk of complications. In a retrospective study with 475 patients submitted to open supraclavicular sympathectomy, early postoperative complications were observed such as Horner syndrome (12%), pneumothorax (6%) and pleural effusion (4%). Late postoperative complications were compensatory sweating (80%), metal taste sensation (53%), respiratory discomfort (22%) and pain at operating wound (12%) 8. It is assumed that the high incidence of complications (Horner syndrome, pneumothorax and pleural effusion) associated to sympathectomy by thoracotomy is a consequence of tissue injury during surgical dissection.
There are few prospective randomized studies comparing surgical follow up and the incidence of complications between both procedures. In a prospective randomized study with 24 patients allocated for bilateral supraclavicular thoracic sympathectomy and bilateral thoracoscopic sympathectomy, postoperative pain has lasted longer for the thoracoscopy group 10. Surgery length was 157 minutes for thoracotomy group and 25 minutes for thoracoscopy. There have been no significant differences between both techniques. Exact post-thoracoscopy chest pain mechanism has remained unexplained.
There may be compensatory hyperhydrosis in back, buttocks and thighs regardless of the technique. Exact mechanism of this condition is still unexplained but it is suggested that compensatory hyperhydrosis is caused by changes in sudomotor and thermoregulation functions. As compared to preoperative condition, compensatory hyperhydrosis is in general mild.
Patients submitted to thoracoscopic sympathectomy should be previously informed about the procedure, its success rate, possible complications, postoperative chest pain and late compensatory sweating. The procedure is brief and may be performed in outpatient regimen. Most patients submitted to this procedure are young, sometimes teenagers, previously healthy and, unless history or physical evaluation indicates, there is no need for preoperative lab tests 11 Base of lung X-rays are indicated to help diagnosing pulmonary adherences and evaluating possible postoperative complications. Preanesthetic medication is indicated depending on anesthesiologist's evaluation; preference is given to short-duration benzodiazepines administered soon before the procedure.
Adequate monitoring decreases potential post-anesthetic accidents by identifying abnormalities before they become severe or irreversible injuries. As in any surgical procedure, routine monitoring during thoracoscopic sympathectomy includes ECG, pulse oximetry, noninvasive blood pressure and capnography 12. Pulse oximetry is needed because there are always ventilatory changes attributed to single lung ventilation, to periods of apnea or to intrapleural carbon dioxide inflation. Early hypoxemia diagnosis during single lung ventilation or after pulmonary inflation in the operating side requires vigilance and adequate SpO2 monitoring. When carbon dioxide inflation is used, capnography results are important to early diagnose incorrect Verre's needle positioning, inadvertent pulmonary puncture and hypertensive pneumothorax.
After being adequately monitored and having their vital signs measured, patients are submitted to peripheral venous puncture. 20 and 18G catheters are recommended in distal upper limbs to prevent folds which may impair drugs and fluids infusion during patients' final positioning. Sympathetic chain is located in the posterior chest wall, covered by pulmonary parenchyma. For adequate surgical exposure, ipsilateral lung has to be collapsed or retracted and this may be achieved by single lung ventilation with double lumen catheter, carbon dioxide inflation in association to single lumen catheter and, more recently, laryngeal mask has been described for this procedure 13.
General Anesthesia Induction and Maintenance
Chest sympathectomy is usually a brief procedure, so drugs should be potent, of short duration and associated to few undesirable effects. While inhalational agents administration is cheaper and easier, total intravenous anesthesia with propofol continuous infusion has the advantage of not interfering with pulmonary hypoxic vasoconstriction during single lung ventilation 14 and of offering faster and more foreseeable emergence allowing for shorter recovery time and hospital stay.
Primary technique is anesthetic induction with propofol (1 to 2 mg.kg-1), fentanyl (5 to 7 µg.kg-1) and atracurium (20 to 40 mg), followed by maintenance with 0.5 to 1 MAC isoflurane and 50% to 60% nitrous oxide and oxygen. Continuous propofol and alfentanil infusion associated to atracurium for tracheal intubation and 50% oxygen are described for total intravenous anesthesia.
Patients' positioning depends on the experience of each service and on surgeons' preference. Arms may be 90º abducted and patients placed in the semi-sitting position; they may be maintained in the lateral position with 90º to 120º arms abduction or they may be placed in the supine position with 90º arms abduction.
Verre's needle is then inserted in the interpleural space through a small incision at the fourth intercostal space, in the median axillary line with the ipsilateral lung collapsed, partially collapsed or even compressed by carbon dioxide inflation. Capnography is used to confirm correct Verre's needle positioning and to rule out accidental pulmonary puncture.
Anesthesia with Double Lumen Catheter
It is associated to adequate surgical exposure and low risk of pulmonary injuries, such as stellate ganglion and chest blood vessels injuries. Adequate catheter positioning should be confirmed by observation and auscultation. Initial auscultation is bilateral with inflated tracheal cuff, then bronchial cuff is inflated and auscultation is bilateral after interrupting catheter branches, one at a time.
Fibrobronchoscopy may also confirm adequate positioning, however it is not always available, requires qualified personnel and makes the process more expensive 15. Incorrect catheter positioning may lead to difficulties in collapsing ipsilateral lung with risk of pulmonary injury and difficulties in performing the technique by inadequate exposure. Once the catheter is adequately placed, patient is positioned for surgery and ipsilateral double lumen branch is interrupted and opened to atmosphere. The objective is to separate visceral from parietal pleura, which helps preventing pulmonary injuries by trocar, needle and endoscope insertion. During anesthesia with single lung ventilation, chest inflation with carbon dioxide becomes redundant and adds undesirable hemodynamic effects to the procedure.
Anesthesia with Single Tracheal Tube
Tracheal tube is fast and easily positioned, not requiring specialized people or equipment to confirm its adequate positioning which, sometimes, may make its use more affordable as compared to double lumen catheter. Notwithstanding these advantages, cost-benefit ratio should be taken into consideration since there are failures in collapsing ipsilateral lung and, when associated to carbon dioxide inflation, single lumen catheter may contribute to higher risk of respiratory and hemodynamic complications.
Immediately after general anesthetic induction and before needles or trocars insertion, apnea is performed and expiratory valve is opened to atmosphere to prevent pulmonary injury by surgical instrumentation. As opposed to double lumen anesthesia, there is the possibility of associating continuous interpleural space carbon dioxide inflation with single lumen catheters. This helps ipsilateral lung compression by continuous intrapleural positive pressure, thus promoting good surgical exposure. Major disadvantages of single lumen technique are: fast pulmonary expansion with decreased intrapleural pressure which obstructs surgical field, difficulty in administering inhalational anesthesia and the presence of hypoxemia and hypercarbia when apnea is needed for the procedure.
Major postoperative cares are early diagnosing pneumothorax and residual hemothorax, preventing nausea and vomiting and adequate postoperative pain control. In most cases, the postoperative period is free from complications and patients are discharged after one night stay or in the same day. Since clinical decisions are based on radiological findings, postoperative chest X-rays are needed. Regardless of the technique, the incidence of postoperative pneumothorax varies from 2% to 15% 16. Since lung is inflated under direct view, it is believed that this complication is technique-dependent. When residual pneumothorax is diagnosed, the extension of pulmonary collapse should be evaluated to determine the need for intercostal drainage. In a study by Gothberg et al. 9, postoperative chest X-rays were obtained from 1274 patients and revealed a small apical pneumothorax area in 602 cases (5 ± 1 mm); from these, 6 needed chest drainage due to radiological evidence of pneumothorax expansion.
Nausea and vomiting imply longer observation, maintenance of venous access and hydration, delay in feeding and administration of analgesic and anti-inflammatory drugs 17. Major predisposing factors are previous history of post-anesthetic nausea and vomiting, high intraoperative opioid doses, young patients, females, gastric distension and postoperative pain. Recommended treatment is droperidol (0.625 to 1.25 mg) associated to dexamethasone (8 to 10 mg). Intravenous ondansetron (4 mg) may be administered if droperidol is not effective, or prophylactically if there is previous history of severe post-anesthetic nausea and vomiting 18.
Postoperative pain is common and more severe in the first 2 to 4 postoperative hours. Pain is in general characterized as retro-sternal or in the upper chest region close to shoulders. It is in general related to incisions and its exact mechanism is not well explained. It is believed that when intrapleural carbon dioxide inflation is used, mediastinum shift results in pleural stretch and pain pathways activation 19. NSAIDs, except for counterindications, may be used for post thoracoscopy pain, being an effective and safe alternative to opioids and decreasing their postoperative need 20. Due to slower NSAIDs onset as compared to the short length of thoracoscopic sympathectomy there is in general need to supplement analgesia with opioids. Most common are fentanyl, meperidine or morphine. Oral acetoaminophen (500 to 1000 mg), associated or not to codeine, and oxycodone may be administered if patient is awaken 18.
Thoracic sympathectomy is an effective method to treat palmar hyperhydrosis and the number of procedures is increasing. Thoracoscopy has improved the technique, and decreased morbidity, surgical length and hospital stay. Adequate anesthetic management, continuous monitoring and available techniques allow the procedure to be safely performed or that approaches are changed according to clinical observations and patients' responses to dynamic changes induced by surgery and drugs. It is up to the anesthesiology to make judicious and sensible use of available techniques to assure safe procedure and fast recovery with the least possible morbidity.
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Dr. Airton Bagatini
Address: Rua Santana, 483/301
ZIP: 90040-373 City: Porto Alegre, Brazil
Submitted for publication August 11, 2004
Accepted for publication January 20, 2005
* Received from Centro de Ensino e Treinamento do SANE, Porto Alegre, RS