Thoracoscopic sympathetic block to predict compensatory hyperhidrosis in primary hyperhidrosis

Abstract

Background: Compensatory hyperhidrosis is the main cause of patients' dissatisfaction following sympathectomy for primary hyperhidrosis. Therefore, thoracoscopic sympathetic nerve block before sympathectomy can be used to predict compensatory hyperhidrosis after sympathectomy. The objective of this study is to review our recent experience with the nerve block procedure, describing efficacy, safety and validity.Methods: We retrospectively reviewed the medical records of 107 patients who underwent thoracoscopic sympathetic nerve block with a local anesthetic for primary palmar and craniofacial hyperhidrosis using a 2-mm needlescope from March 2017 to November 2019. A week later, the patients were interviewed, and a decision made as to whether to proceed with sympathectomy. We analyzed the perioperative data of patients who underwent the predictive procedure either followed, or not followed, by sympathectomy. Results: Primary hyperhidrosis was relieved in all patients by the predictive procedure without severe complications. Compensatory hyperhidrosis happened to 32 patients (29.9%). Seventy-eight patients (72.9%) decided to undergo sympathectomy (group A) and 29 patients (27.1%) refused the sympathectomy (group B). Group B tended to have higher average body mass index (24.5 versus 23.2 kg/m 2 , P=0.082) and compensatory hyperhidrosis rate after predictive procedure (37.9% versus 26.9%, P=0.269) compared to group A. The compensatory hyperhidrosis rate after sympathectomy in group A was 76.9%. The effective duration of sympathetic block was significantly longer in group A than in group B (33.5 versus 13.9 hours, P=0.001). The predictive procedure had 94.4% specificity and 33.3% sensitivity for prediction of compensatory hyperhidrosis.Conclusions: Thoracoscopic sympathetic block may be safe and feasible as a procedure for predicting compensatory hyperhidrosis after sympathectomy, and beneficially, it allows the patients to experience the effect of sympathectomy on primary hyperhidrosis and occurrence of compensatory hyperhidrosis. However, a longer effective duration of sympathetic block is needed to help patients to decide whether to proceed with the surgery.

Use of thoracoscopy for thoracic sympathetic nerve block in primary hyperhidrosis

“…Sun and his colleagues reported that high thoracic sympathetic block improved myocardial capillary spasm and growth. TSNB can also be applied as a predictive procedure for compensatory hyperhidrosis before sympathectomy in primary hyperhidrosis, based on the effect of sympathetic block on increasing skin perfusion and temperature through vasodilation at the anesthetized sites (10,11,19,20).…”

“…Over the past decades, there have been several approaches to blocking thoracic sympathetic nerve: the landmark-based approach, US-guided approach, CT-guided approach, uoroscopically, and thoracoscopically (10)(11)(12)(13)(21)(22)(23). A classic technique that does not use image guidance is a landmarkbased approach that elicits a loss of resistance (21).…”

“…However, patients are hesitant to undergo thoracoscopic sympathectomy due to the possible occurrence of postoperative compensatory hyperhidrosis, which happens in 50-90% of patients, and is particularly likely in patients with craniofacial hyperhidrosis (4)(5). Since there is no effective treatment for postoperative compensatory hyperhidrosis after de nite sympathectomy, many authors have proposed several strategies including limited level sympathectomy (6), lower level sympathectomy (7,8), sympathetic nerve clipping (9) and temporary thoracoscopic sympathetic block (10,11).…”

“…However, these approaches appear to be less accurate than the thoracoscopic approach, which allows the surgeons to visualize a targeted sympathetic nerve in their own eyes. In 2009, we started conducting thoracoscopic TSNB under local anesthesia with a 2-mm single incision not only to reduce invasiveness but also to enhance our accurateness during the surgical procedure (11).…”

How to Prevent, Reduce, and Treat Severe Post Sympathetic Chain Compensatory Hyperhidrosis: 2021 State of the Art

“…With this goal in mind, Lee et al in the past 10 years developed a procedure to obtain a temporary nerve block to simulate definitive sympathectomy and predict after surgery outcomes of patient (23). In particular, they introduced a thoracoscopic sympathetic block under local anesthesia.…”