Clipping versus Division of Sympathetic Chain in Thoracoscopic Sympathectomy for Treatment of Primary Palmar Hyperhidrosis

INTRODUCTION

Primary palmar hyperhidrosis (PH) is a condition that is idiopathic and may be embarrassing socially, emotionally, and professionally. The sympathetic nervous system innervates eccrine sweat glands, which are responsible for PH development. Excessive sweating can be caused by increased sympathetic activity, which happens spontaneously or as a result of an inappropriate central response to increasing temperature or emotional disturbances.¹Conservative  therapy of PH, like medicine (anticholinergic medications), Botox, or iontophoresis, generally gives transient relief, and such nonsurgical therapies are not without related adverse impacts.^2,3 The surgical PH treatment (video-thoracoscopic sympathectomy) has been shown to be effective and dependable.^4,5 Patient dissatisfaction using sympathectomy, on the other hand, has prompted a rethinking of the surgical strategy. Compensatory hyperhidrosis (CH) has been shown to affect patient satisfaction and life quality. The procedure was developed in order to improve patient satisfaction, and it now has a high rate of success and fewer negative impacts. ⁶ For individuals experiencing palmar and palmoaxillary sweating, limited sympathetic chain disruptions below the R2 ganglion level were indicated to minimize reduce CH.⁷ In spite of the fact that both approaches offer good outcomes if the amount of division is right, there is a controversy about the optimal surgical method for sympathectomy if disruption by electrocautery or blockade using clips must be employed. While contentious, clipping's potential for reversibility makes it a better option than cauterization. In this work, we compared the effectiveness, recurrence, and reversibility of sympathetic chain disruption approaches.

PATIENTS AND METHODS

A total of twenty eligible consecutive patients with primary palmar hyperhidrosis were managed using a bilateral, thoracoscopic approach in a prospective and randomized clinical study carried out from January 2021 to November 2021 at the AL-Azhar University Hospitals' Department of General Surgery (AL-Hussein and Sayed Galal) in Cairo, Egypt. Ten patients underwent sympathetic chain cutting (group A), and the other ten patients were applyed endo-clips over the sympathetic chain (group B). All patients underwent a thorough history and physical exam, as well as routine pre-operative investigations (CBC, ALT, AST, serum creatinine, INR), and pre-operative antibiotic prophylaxis. A double-lumen endotracheal tube was used to perform thoracoscopic sympathetic surgery while the patient was in a supine location, having both arms lifted and supported to 90° under general anesthesia. A 10-mm, 30° telescope has been inserted through the first port, which has been inserted into the level of the fifth intercostal space's mid-axillary line. Another port was inserted in the anterior axillary line at the fourth intercostal space, with a port size of 5 mm in group A for the insertion of endoscopic instruments and a port size of 10 mm in group B for clip appliers. The lung will then be progressively deflated by inserting 1,500–1,700 mL of CO2 gas into the thoracic cavity. The costal pleura will be opened across the major sympathetic trunk employing diathermy. In group A, the sympathetic chain has been dissected by diathermy at the level of the superior border of the second and third ribs; in group B, the sympathetic chain was clipped at the same level employing an endoclip (Ligaclip, Ethicon, USA); in both groups A and B, the putative bypass nerve fibers were amputated, extending the transection range by roughly 3 cm laterally across the relevant rib surface. A 10-Fr chest tube has been inserted into the pleural cavity, the lung has been inflated, and the chest tube has been withdrawn after air escape ceased. We generally performed the surgery on the right side first, then the contralateral site. The majority of patients have been discharged on the same day or the following day after a routine chest x-ray has been done for them and the follow-up parameters were: dryness of the hand within 24 hours, dryness of the combined hand and axilla, compensatory sweat appearance after surgery, patient satisfaction, and the occurrence of complications, e.g., manifestations of Horner syndrome.The IBM SPSS software package version 20.0 has been employed to analyze the data that was supplied to the computer. (Armonk, NY: IBM Corp).  Numbers and percentages have been employed to describe qualitative data. Range (min and max), mean, standard deviation, and median have been employed to describe quantitative data. The significance of the acquired findings has been determined at the 5% level. The tests performed were the chi-square test for categorical variables and the Monte Carlo correction for chi-square when more than 20% of the cells had an anticipated count of less than 5. To compare two examined groups, use the Student t-test for normally distributed quantitative variables.

RESULTS

Demographic data-based distribution of the examined cases: (table 1)

Our sample included a total of 20 eligible patients with a mean age 20.40 ± 2.3 years, randomized into two equal groups that were statistically matched. Of them, 55% were males. All patients had bilateral hyperhidrosis, 25 % had only palmar hyperhidrosis and 75% had combined hyperhidrosis (palmar plus either axillary or plantar or both).

Table 1: Comparison of examined groups based on demographic data.

T: independent sample T test. NS: p-value > 0.05 is deemed non-significant.

X2: Chi-square test.

This table shows no statistically significant difference (p-value > 0.05) between examined groups based on demographic data (age, sex, side and site). As regard age, the mean age in group A was 21.6 ± 3.02 years with minimum age of 17 and maximum age of 26 years while the mean age in group B was 21 ± 2.2 years with minimum age of 18 and maximum age of 24 years. As regard sex, there were 6 men (60%) and 4 women (40%) in group A while there were 5 males (50%) and 5 females (50%) in group B. As regard laterality, all studied patients (100%) in both groups were bilateral. As regard site, there were 3 palmer (30%) and 7 combined (70%) in group A while there were 2 palmer (20%) and 8 combined (80%) in group B.

Fig. 1: Comparison between the study groups in terms of age.

Fig. 2: Comparison between the study groups in terms of sex.

Fig. 3: Comparison between the study groups in terms of site

Table 2: Comparison between the study groups based on complications.

X2: Chi-square test.                                                NS: p-value > 0.05 is deemed non-significant.     

This table shows no statistically significant difference (p-value > 0.05) between the examined groups based on complications (intra-operative bleeding, conversion to thoracotomy, intra-operative chest tube insertion, superficial wound infection and Horner’s syndrome). No patient in both groups developed Horner syndrome or converted to thoracotomy. in the group A one patient (10%) who had bleeding intraoperative. This patient later on developed superficial wound infection (10%). Also one patient (10%) needed chest tube insertion intra-operatively instead of tubeless operation.

Fig. 4: comparison between the study groups based on complications.

Table 3: comparison between the study groups based on treatment success follow up.        

 HS: p-value < 0.001 is deemed highly significant.

X2: Chi-square test.                                                NS: p-value > 0.05 is deemed non-significant.     

This table shows:

Based on dryness of hand after 24 hours, there was a highly statistically significant difference (p-value < 0.001) between the examined groups. In group A, all patients 10 (100%) showed significant dryness of the hand on the spot or within the first 24 hours, while only 1 (10%) patient in group B showed complete dryness within the first 24 hours (p= 0.0002). In group B, 8 (80%) patients showed nearly dry hand and 1 (10%) patients showed wet hand on spot or in the first 24 hours.

There was no statistically significant difference (p-value > 0.05) between the examined groups based on dryness of combined hand and axilla, compensatory sweat, and patient satisfaction.

Fig. 5: comparison between the study groups based on the dryness of hand within 24 hour.

Fig.6: Comparison between the study groups based on dryness of the combined hand and axilla.

Fig. 7: Comparison between the study groups based on compensatory sweat.

Fig. 8: Comparison between the study groups based on patient satisfaction.