Upload
shiela
View
49
Download
2
Embed Size (px)
DESCRIPTION
Differens options in thoracoscopic sympathectomy. Hans Pilegaard, Ass. Prof, MD Department of Cardiothoracic Surgery Aarhus University Hospital, Skejby Denmark 13th Turkish Thoracic Society Congress Istanbul Turkey. Hyperhidrosis. National questionnaire 150.000 households - PowerPoint PPT Presentation
Citation preview
Differens options in thoracoscopic
sympathectomy
Hans Pilegaard, Ass. Prof, MD
Department of Cardiothoracic SurgeryAarhus University Hospital, Skejby
Denmark
13th Turkish Thoracic Society CongressIstanbul Turkey
Hyperhidrosis
Strutton et al. J Am Acad Dermatol 2004; 51:241-248
National questionnaire 150.000 householdsUS prevalence 2.8%
7.8 millions individuals
4 millions axillarwork
emotionalpsychologicalsocial
Hyperhidrosis
• Blushing• Facial• Palmar• Axillary• Foot
• Raynaud syndrome• Cardiac arrhytmia?• Angina pectoris?
Thoracoscopic treatment
Topical
Aluminium chloride (AlCl3-6H2O)
Anticholinergic agentsAstringent agents (Glutaraldehyde, formalin)IontophoresisBotulinum toxin
Excision of glands in the axillary regionLiposuctionLaser treatment
Thoracotomy Kotzareff 1920 Kotzareff A. Rev Med Suisse Romande 1920; 40:111-
113
Supraclavicular approach Telford 1935Telford E. Br J Surg 1935; 23:448-450
Anterior approach Polumbo 1956Polumbo LT. Arch Surg 1956;72:659-66
Transaxillary Goets & Marr 1944Goets R, Marr J. Clinical Proceedings 1944; 3:102-114
Posterior Adson 1929Cloward 1969Cloward. J Neurosurgery 1969; 30:545-551
Axillar extrapleural Roos 1971Roos D. Ann Surg 1971; 173:429-442
Open sympathectomy
Thoracoscopy Hughes 1942Hughes J. Proc Royal Soc Med 1942; 35:585-586
Thoracoscopy Goets & Marr 1944Goets R, Marr J. Clinical Proceedings 1944; 3:102-
114
Thoracoscopy Kux 1946-54Kux E. Georg Thieme Verlag, Stuttgart 1954
VATS 1980´s -
Thoracoscopic sympathectomy
Thoracoscopic sympathectomy
EasyFast (minuttes)Good visualizationSmall incisions
OutpatientAwakeLocal anaestesia
Elia et al. Awake one stage bilateral thoracoscopic sympathectomy for palmar hyperhidrosis: A safe outpatient procedure. 2nd EACTS/ESTS joint meeting, Leipzig, Germany 2004
Definitions
• Sympathotomy– Transection
• Sympathectomy– Resection– Ablation
Thoracoscopy
• Needle, 5mm, 10mm
• Uniportal• 2 ports• 3 ports can be necessary
Methods
• Electrocoagulation• Harmonic scalpel• Laser• Clipping
– Reversal
Electric vs harmonic scalpel
• Non randomized prospective• N=1515 patients• 24 hours, 7 days and 30 days• Responserate: 90%/68%/27%• No difference either by method or
level
de Campos JR et al. ICVTS: in press JR
Clipping
• N=727 patients – responsrate 92%• T2: 399, T2+3: 55, T3+4: 273• 34 patients have had clip removed• T2: 21, T2+3: 7, T3+4: 6 • 15 patients. decrease in
compensatory sweating
Sugimura H et al. J Thor Cardiovasc Surg 2009;137(6): 1370-8
Supine Single lumen tube
Harmonic scalpelTwo ports
Method
Reverse Trendelenburg
Blushing Th 2
Palmar Th 2-3 Axillary Th 2-3-4
Sympathectomy level
Sympathicotomy - left
Facial blushing and hyperhidrosis
T1-T2-T3 Drott et al. Br j Dermatol 1998;138:639-43.
T2 Kim et al. Eur J Cardiothor Surg 2004;26:396-400
Doolabh et al. Ann Thor Surg 2004;77:410-4Dewey et al. Ann Thor Surg 2006;81:1227-33Chou et al. Surg Endoscpo 2006;20:1749-53Licht et al. Ann Thor Surg 2006;81:1863-6Weksler et al. Thorac Surg Clin 2008;18:183-191
T2-T3 Drott et al. J Cosmet Dermatol 2000;1:115-9
Licht et al. Ann Thor Surg 2006;81:1863-6
Facial blushing and hyperhidrosis
• Follow-up questionaire – 2 centers• N=189 • Responsrate 96%• Outcome similar• Compensatory sweating• T2 83% - T2-3 95% p=0.02
Licht et al. Ann Thor Surg 2006;81:1863-6
Facial blushing
• RCT• T2 vs T2-T3• Study size n=200• N= 55• No difference
+200 papers
Most recommend T2-T3
Palmar hyperhidrosis
Chiou TS & Chen SC. Br J Surg 1999; 86:45-47Reisfeld R et al. Surg Laparosc Endosc Percutan Tech 2002; 12:255-267Kao MC. Ann Thorac Surg 2001; 72:667-668Andrews & Rennie JA. Br J Surg 1997; 84:1702-1704Lin CC. Surg Endosc 1990; 4:224-226
T2
Dumont P et al. Ann Thorac Surg 2005; 78:1801-1807 Zacherl J et al. Ann Thorac Surg 1999; 68:1177-1181 Gossot D et al. Ann Thorac Surg 2003; 75:1075-1079
Yilmaz EN et al. Eur J Cardiothorac Surg 1996; 10:168-172Lardinois D & Ris HB. Eur J Cardiothorac Surg 2002; 21:67-70Nicholson ML et al. Ann R Coll Surg Engl 1994; 76:311-314
T2-T4
T2-T5
T2 vs T3Palmar hyperhidrosis
• N= 60 patients• Succesrate: 59/60• Compensatory hyperhidrosis
– No differens in number, but in severity
– T2/T3: 13/4 p= 0.007
Yazbek G et al: Clinics 2009;64(8):743-9Yazbe
T3 vs T2-T4Palmar hyperhidrosis
• N= 232 patients
Compensatorysweating
T2-4N=115
T3N=117
p
N= 33 25
Mild 15 12
Moderate 7 9
Severe 11 4 < 0.05
Xu Li et al. Ann Thor Surg 2008;85:1747-52
Axillary hyperhidrosis
T2-T4 Zacherl J al. Ann Thorac Surg 1999; 68:1177-1181Hsu CP et al. Arch Surg 2001; 136:1115-1117Dumont P et al. Ann Thorac Surg 2005; 78:1801-1807 Rex LO et al. Eur J Surg Suppl 1998;23-26 Drott C & Claes G. Cardiovasc Surg 1996; 4:788-790 Ahn SS et al. Ann Vasc Surg 2000; 14:415-420
T2-T3 Fox AD et al. Eur J Vasc Endovasc Surg 1999; 17:343-346Andrews BT & Rennie JA. Br J Surg 1997; 84:1702-1704Kao MC et al. Ann Acad Med Singapore 1996; 25:673-678
T2 Chiou TS & Chen SC. Br J Surg 1999; 86:45-47
T4 vs T3-4Axillary hyperhidrosis
• N= 64 patients• RCT
Compensatory sweating
T3-4 T3 p T3-4 T3 P
Mild 16 14 18 13
Moderate
11 2 < 0.001
11 1 < 0.001
6 mdr 12 mdr
Munia MAS et al. Clinics 2008;63(6);771-4
Compensatory sweating
• N=158 patients• Responsrate 89%
– T2 facial blushing and hyperhidrosis– T2-3 palmar hyperhidrosis– T2-4 axillary hyperhidrosis
Level of sympathectomy
Severe sweating %
T2 21
T2-3 36
T2-4 49
Licht et al. Ann Thor Surg 2004;78:427-31
P=0.04
Gustatory sweating
• N=238 patients• Responsrate 96%• Gustatory sweating 32%
Level of sympathectomy
Gustatory sweating %
T2 27
T2-3 29
T2-4 44
Licht et al. Ann Thor Surg 2006;81:1043-7
P=0.04
Information to the patient
• Succes rate• Sideeffects
– Compensatory sweating– Gustatoric sweating– Horner’s syndrome– Heart rate
• Definitiv operation• Telarenta T. Eur J Surg Suppl 1998;580:17-8
Succesrate
• Facial blushing and hyperhidrosis 90%
• Palmar hyperhidrosis100%
• Axillary hyperhidrosis 80%
Sideeffects
• Compensatory sweating 90%• Gustatoric sweating 35%• Horner’s syndrome > 1%• Heart rate at rest 10%
• Dry hands
• Return to basic not a possibility
Side effect - Harlequin
Eur J Cardiothor Surg 2010;37:959
• 1997-2007• N=669• 48 reoperation
Number
Improved
Unilateral 29 96%
Bilateral 6 50%
recurrence 13 75%80% compensatory sweating38% worsening
Licht et al. Ann thor Surg 2010;89:1087-90
Conclusion
T2 for facial blushing and hyperhidrosis
T3 for palmar hyperhidrosis
T4 for axillary hyperhidrosis
Conclusion
Most patients are satisfied with the operation
90% of the patients will get compensatory sweating
Signifikant compensatory sweatingis more frequent after
T2-4 sympathectomi for axillary hyperhidrosis
Good information before the operationis mandatory
Conclusion