Video-assisted thoracic sympathectomy: literature review.

Nicolini, Eveline Montessi; Costa, Víctor de Oliveira; Montessi, Jorge; Rodrigues, Guilherme de Abreu; Cangussu, Victor Vitoi; Reis, Ana Flávia Miranda; Marques Filho, Flávio Vieira

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Review Article • Rev. Col. Bras. Cir. 46 (2) • 2019 • https://doi.org/10.1590/0100-6991e-20192157 copy

Video-assisted thoracic sympathectomy: literature review.

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT.

Thoracic sympathectomy has been effective in relieving hyperhidrosis in several patients, with quality of life improvement. The knowledge of the clinical picture of each patient, as well as the possible postoperative complications, are fundamental to obtain good results. Thus, we performed a review of articles from the PubMed database published between 2005 and 2019 that presented, as the main topic, thoracoscopy sympathectomy for the treatment of hyperhidrosis, with the objective of evaluating the current state of art referring to postoperative quality of life, surgical time and its complications. From this analysis, we verified the importance of the level of sympathetic ganglion chain section in relation to results. The complication, although occurring, did not reduced the postoperative level of satisfaction or patients' quality of life.

Keywords:
Sympathectomy; Hyperhidrosis; Quality of Life; Thoracic Surgery, Video-Assisted

Study	Methods	Patients (n)	Postoperative/Discharge	Conclusion
Akil et al. (2018)³3 Akil A, Semik M, Fischer S. Efficacy of miniuniportal video-assisted thoracoscopic selective sympathectomy (Ramicotomy) for the treatment of severe palmar and axillar hyperhidrosis. Thorac Cardiovasc Surg. 2018 May 8. doi: 10.1055/s-0038-1642030. [Epub ahead of print]. https://doi.org/10.1055/s-0038-1642030...	Data collected prospectively and analyzed retrospectively.	51	At discharge, all patients reported hot and dry hands and axillae, a fact they also reported four weeks later.	There was no evidence of compensatory sweating, demonstrating treatment effectiveness.
Silva Sobrinho et al. (2017)⁴4 Silva Sobrinho SL, Fiorelli RKA, Morard MRS. Evaluation of the quality of life of patients with primary hyperhidrosis submitted to videothoracoscopic sympathectomy. Rev Col Bras Cir. 2017;44(4):323-7.	Applied questionnaire on hyperhidrosis-related quality of life from the preoperative period up to one year after the operation.	122	Compensatory hyperhidrosis occurred in 78% of the patients, affecting more than one body segment in 83% of the cases.	Thoracoscopic sympathectomy improves the quality of life of patients with primary hyperhidrosis. Transient compensatory hyperhidrosis occurred in most patients, but did not significantly alter the improvement in quality of life.
Dias et al. (2016)⁵5 Dias LI, Miranda EC, Toro IF, Mussi RK. Relationship between anxiety, depression and quality of life with the intensity of reflex sweating after thoracoscopic sympathectomy for treatment of primary hyperhidrosis. Rev Col Bras Cir. 2016;43(5):354-9.	Two questionnaires were applied in three different moments: "Quality of life" in patients with primary hyperhidrosis and "Scale for anxiety and depression"	54	After 30 days of surgery, 87% of patients rated their quality of life in relation to hyperhidrosis as much better, 9% slightly better, 2% as the same and 2% as much worse.	Thoracoscopic sympathectomy improves the quality of life of patients with primary hyperhidrosis, even with the emergence of reflex sweating. Anxiety is directly related to the intensity of the reflex sweating, without compromising the degree of patient satisfaction.
de Campos et al. (2017)⁶6 de Campos JRM, Lembrança L, Fukuda JM, Kauffman P, Teivelis MP, Puech-Leão P, et al. Evaluation of patients who underwent resympathectomy for treatment of primary hyperhidrosis. Interact Cardiovasc Thorac Surg. 2017;25(5):716-9.	Assessed levels of sympathectomy resection, technical difficulties, surgical complications, preoperative quality of life, treatment response and improved quality of life 30 days after surgery.	15 patients from an initial group of 2300 submitted to resympathectomy after failure of primary surgical treatment.	After surgery, 11 patients considered their quality of life excellent, three very good, and one, good.	Resympathectomy is an effective procedure and improves the quality of life in patients with primary hyperhidrosis whose first surgery failed.
Baroncello et al. (2014)⁷7 Baroncello JB, Baroncello LR, Schneider EG, Martins GG. Evaluation of quality of life before and after videothoracoscopic simpathectomy for primary hyperhidrosis. Rev Col Bras Cir. 2014;41(5):325-30.	Patients submitted to thoracoscopic sympathectomy for the treatment of primary palmar and axillary hyperhidrosis, and the association of the two. Applied a questionnaire on hyperhidrosis-related quality of life before and after the operation.	51	The mean quality of life related to hyperhidrosis, in a score of 0 to 100, before the sympathectomy was 34.6, and after the operation, 77.1. Compensatory hyperhidrosis occurred in 84.3% of the patients.	Thoracoscopic sympathectomy improves the quality of life of patients with primary hyperhidrosis, maintaining this result over time. Compensatory hyperhidrosis occurred in most patients, but did not significantly influence the improvement in quality of life.
Ibrahim et al. (2013)⁸8 Ibrahim M, Menna C, Andreetti C, Ciccone AM, D'Andrilli A, Maurizi G, et al. Bilateral single-port sympathectomy: long-term results and quality of life. Biomed Res Int. 2013;2013:348017.	A study of 260 consecutive, bilateral, thoracoscopic sympathectomies that were performed in 130 patients for primary axillary and primary hyperhidrosis through single-port access.	130	No operative mortality or conversion to open surgery. Decreased heart rate observed one year after surgery and permanently over time. There was no relapse during the follow-up period (31.5 months) and 90% of patients reported improvement in quality of life.	Bilateral, one-stage, mini-uniportal thoracoscopic sympathectomy is a valid and safe treatment for primary hyperhidrosis, obtaining definitive and esthetic results, with excellent patient satisfaction. Compensatory sweating may occur.
Zhu et al. (2014)⁹9 Zhu LH, Du Q, Chen L, Yang S, Tu Y, Chen S, et al. One-year follow-up period after transumbilical thoracic sympathectomy for hyperhidrosis: outcomes and consequences. J Thorac Cardiovasc Surg. 2014;147(1):25-8.	All procedures were performed transumbilically under general anesthesia and the patients were intubated with a double lumen endotracheal tube.	35	Success rate after 12 months was 97.1% (34 of 35) for isolated palmar hyperhidrosis and 72.2% (13 of 18) for axillary hyperhidrosis. Compensatory sweating was reported by 28.6% of patients at the one-year follow-up evaluation. Hyperhidrosis-related quality of life improved substantially in 27 (77.1%) patients.	Transumbilical thoracic sympathectomy is an effective alternative to the conventional approach. This technique avoided chronic chest pain and paraesthesia associated with the thoracic incision. In addition, this new procedure provided maximum cosmetic benefits.
Raposio et al. (2015)¹⁰10 Raposio E, Caruana G. Video-assisted thoracic sympathicotomy for the treatment of palmar and axillary hyperhidrosis: a 17-year experience. Surg Laparosc Endosc Percutan Tech. 2015;25(5):417-9.	Questionnaires applied to randomized patients, both to evaluate results’ persistence and quality of life after surgery.	720	In 46 patients, distinct anatomical features obscured the sympathetic chain, partially or totally preventing the of the procedure. The other 674 patients reported complete relief of symptoms.	When comparing pre- and postoperative results, there was a statistically significant difference between the majority of responses.
Wolosker et al. 2010)¹¹11 Wolosker N, Munia MA, Kauffman P, Campos JR, Yazbek G, Puech-Leão P. Is gender a predictive factor for satisfaction among patients undergoing sympathectomy to treat palmar hyperhidrosis? Clinics (Sao Paulo). 2010;65(6):583-6.	Examine whether gender interferes with quality of life after surgery and whether the quality of life before the procedure interferes with the analysis in the postoperative period.	1044	No statistically significant differences between genders regarding quality of life in patients with palmar hyperhidrosis. At the 30-day postoperative interview, quality of life improved in both groups, with no statistical difference between them.	Patients with palmar hyperhidrosis present improvement in quality of life after video-assisted sympathectomy, regardless of gender.
Neves et al. (2012)¹²12 Neves S, Uchoa PC, Wolosker N, Munia MA, Kauffman P, de Campos JR, et al. 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;29(5):575-9.	Investigated the improvement in quality of life (QoL) of a group of 45 children undergoing or not video-assisted sympathectomy for palmar hyperhidrosis (PH) four years after the initial assessment.	45	Twenty-five patients (83.4%) from the VATS group showed a great improvement in PH, and five (16.6%), partial improvement; 12 (80%) children in the control group had some type of improvement, and three (20%), partial improvement. Two (13.3%) children in the control group and 23 (76.7%) in the VATS group had a great improvement in QoL.	For children with PH and poor QoL, VATS is better than no treatment. It produces better results in relation to sweating and improvement in the quality of life, evidencing that, regardless of age, the video-assisted surgery is the best option.
Burashi (2008)¹³13 Buraschi J. [Videothoracoscopic sympathicolysis procedure for primary palmar hyperhidrosis in children and adolescents]. Arch Argent Pediatr. 2008;106(1):32-5. Spanish.	Surgery consisted of thoracoscopic sympathectomy of T2-T3 ganglia. The operation was performed on both sides.	25	Hyperhidrosis disappeared in 98% of the patients. Decrease in axillary transpiration was found in 16 patients, and in the feet, in six. Regarding satisfaction with the procedure, 22 patients were very satisfied, two were satisfied, and one, moderately satisfied.	The results obtained with this technique allow to recommend thoracoscopic sympathectomy for the treatment of this disease in pediatrics.
Ferreira et al. (2018)¹⁴14 Ferreira AP, Ramos OS, Montessi J, Montessi FD, Nicolini EM, Almeida EP, et al. Acompanhamento longitudinal da atividade vagal cardíaca de indivíduos submetidos à simpatectomia torácica endoscópica. J Bras Pneumol. 2018;44(6):456-60.	A descriptive and longitudinal study evaluating mean resting heart rate (HR) by electrocardiogram 20 minutes before the four-second exercise test (4sET), which was used for the assessment of cardiac vagal activity(CVA) on three occasions: before surgery, one month after the surgery and four years after surgery.	22	Mean resting HR presented a significant reduction between the preoperative evaluation and one month after surgery, tending to return to the preoperative values four years after surgery. There was a significant increase in CVA between the preoperative period and one month after surgery, also tending to return to preoperative values after four years of.	The sympathectomy resulted in a change in resting HR and CVA one month after surgery, returning to values close to the preoperative period after four years.
Montessi et al. (2007)²2 Montessi J, Almeida EP, Vieira JP, Abreu, MM, Souza, RLP, Montessi OVD. Simpatectomia torácica por videotoracoscopia para tratamento da hiperidrose primária: estudo retrospectivo de 521 casos comparando diferentes níveis de ablação. J Bras Pneumol. 2007;33(3):248-54.	Compared the degree of satisfaction of the sympathectomized patients and the presence of compensatory sweating according to different levels of ablation. Patients were separated into three groups: Group I thermo-ablation of the sympathetic trunk. Group II: thermo-ablation of the sympathetic trunk, having T3 as the highest level. Group III: thermo-ablation of the sympathetic trunk, having T4 as the highest level.	521	Optimal control of palmar/axillary hyperhidrosis in 94 (82%) of patients in group I, 89 (89%) in group II, and 80 (80%) in group III. Reflex sweating in 67% of patients in groups I and II, falling to 61.29% in group III due to the thermo-ablation at T4. Severe reflex sweating occurred in 32% of patients in group I, 9% in group II, and 4% in group III.	Sympathectomy provided an excellent degree of satisfaction and a low rate of complications. There was no difference in the incidence of reflex sweating with different levels of thermo-ablation, but the intensity of this complication was shown to be lower with lower levels of blockade, mainly T4.

Article	Resection level	Patients (n)	Variables analyzed	Conclusion
Wolosker et al. (2008)²⁴24 Wolosker N, Yazbek G, Ishy A, de Campos JR, Kauffman P, Puech-Leão P. Is sympathectomy at T4 level better than at T3 level for treating palmar hyperhidrosis? J Laparoendosc Adv Surg Tech A. 2008;18(1):102-6.	T3 and T4	1644	Quality of life	Improvement in their quality of life after surgery regardless of patients’ age.
Munia et al. (2007)²⁵25 Munia MA, Wolosker N, Kauffman P, de Campos JR, Puech-Leão P. A randomized trial of T3-T4 versus T4 sympathectomy for isolated axillary hyperhidrosis. J Vasc Surg. 2007;45(1):130-3.	T3-T4 and T4	64	Compensatory hyperhidrosis	Both techniques were effective in the treatment of axillary hyperhidrosis, but the T4 group showed milder compensatory hyperhidrosis and greater patient satisfaction in the follow-up of one year.
Yazbek et al. (2005)²⁶26 Yazbek G, Wolosker N, de Campos JR, Kauffman P, Ishy A, Puech-Leão P. Palmar hyperhidrosis--which is the best level of denervation using video-assisted thoracoscopic sympathectomy: T2 or T3 ganglion? J Vasc Surg. 2005;42(2):281-5.	T2 and T3	60	Compensatory hyperhidrosis	T3-level denervation associated with less severe in CH the immediate postoperative period
Neumayer et al. (2005)²⁷27 Neumayer C, Panhofer P, Zacherl J, Bischof G. Effect of endoscopic thoracic sympathetic block on plantar hyperhidrosis. Arch Surg. 2005;140(7):676-80; discussion 680.	T4	73	Quality of life	Quality of life improved significantly after T4 sympathetic blockade.
Munia et al. (2008)²⁸28 Munia MA, Wolosker N, Kaufmann P, de Campos JR, Puech-Leão P. Sustained benefit lasting one year from T4 instead of T3-T4 sympathectomy for isolated axillary hyperhidrosis. Clinics (Sao Paulo). 2008;63(6):771-4.	T3-T4 and T4	64	Compensatory hyperhidrosis	After one year, all T3-T4 patients had some degree of compensatory hyperhidrosis, compared to only 14 patients in the T4 group.
Yazbek et al. (2009)²⁹29 Yazbek G, Wolosker N, Kauffman P, Campos JR, Puech-Leão P, Jatene FB. Twenty months of evolution following sympathectomy on patients with palmar hyperhidrosis: sympathectomy at the T3 level is better than at the T2 level. Clinics (Sao Paulo). 2009;64(8):743-9.	T2 and T3	60	Compensatory hyperhidrosis and quality of life	Improved quality of life observed from the first postoperative evaluation on, but without any difference between groups. T3 sympathectomy presented compensatory hyperhidrosis with lower severity. Improvement in quality of life was similar between the groups.
Vanderherlst et al. (2011)³⁰30 Vanderhelst E, De Keukeleire T, Verbanck S, Vincken W, Noppen M. Quality of life and patient satisfaction after video-assisted thoracic sympathicolysis for essential hyperhidrosis: a follow-up of 138 patients. J Laparoendosc Adv Surg Tech A. 2011;21(10):905-9.	T2, T3 and/or T4	246	Compensatory hyperhidrosis	In the T4 group, the prevalence of CH was markedly lower (53%) and none of these patients were dissatisfied.

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