Thoracoscopic Sympathectomy versus Thoracoscopic Sympathotomy for The Treatment of Primary Palmar Hyperhidrosis in Children and Adolescents

INTRODUCTION

Hyperhidrosis is a pathologic disease defined by excess sweating that exceeds the body's physiological requirements to sustain an appropriate temperature range .¹

Sweating complaints in primary hyperhidrosis patients typically begin in their first decade of life (especially in the hands), resulting in a detrimental influence on their quality of life (QOL). The symptoms are exacerbated by physical, psychological, as well as emotional stress . ²

However, thoracoscopy sympathectomy is a successful therapy for primary hyperhidrosis of the hands; the effects are irreversible and permanent. Nevertheless, there is still an active dispute concerning the specific form of operation that produces better outcomes, as well as not just the level or levels from which to break the sympathetic chain, but also "sympathotomy" vs. “sympathectomy”.³

When compared to open sympathectomy, the amazing view of the ganglion combined with appropriate magnification enables accurate ganglion division, resulting in reduced occurrences of Horner's syndrome (0.4% to 2.4%) .⁴

A variable level of compensatory sweating, primarily affecting the back, abdomen, and lower extremities, is the most common and worst secondary effect of sympathectomy .⁵

Our rationale was to assess the outcome of boththoracoscopic sympathectomy and sympathotomy for treating primary palmar hyperhidrosis in children and adolescents.

PATIENTS AND METHODS

A randomized comparative prospective study was performed by the Pediatric Surgery Department, Faculty of Medicine, Al-Azhar University during the period from May 2019 to October 2021. The current study involved forty patients diagnosed with primary palmer hyperhidrosis with main diagnostic criteria of visible exaggerated sweat, lasting for at least six months, with an unknown cause after excluding causes of secondary hyperhidrosis (e.g. hyperthyroidism, DM, TB) in addition to at least 2 of the following:

Sweating that is both bilateral and symmetrical.

The weekly occurrence of at least one episode.

Difficulties with day-to-day activities.

The onset age is less than 16 years old.

Presence of family history.

Sleeping without sweating.

All patients were allocated randomly into 2 groups using closed envelops method:

group A (20 patients): has been managed by Thoracoscopic sympathectomy.

group B (20 patients): has been managed by Thoracoscopic sympathotomy.

Ethical approval:

Al-Azhar University's Ethics Board gave their approval for the study. Each individual in the research provided informed written permission.

Inclusion criteria:

Sex: both male and female.

Age: 6 – 18 years.

Patients suffering from bilateral primary palmer hyperhidrosis.

Exclusion criteria:

Patients suffering from secondary hyperhidrosis.

Patients suffering from unilateral primary palmer hyperhidrosis.

Recurrent primary palmer hyperhidrosis.

Methods:

Patients included in the study were subjected to full history taking, clinical assessment, routine preoperative laboratory investigations.

Thoracoscopic sympathectomy technique:

Three ports were used; the first port was a 5 mL port, which was put in the 5th intercostal gap in the mid axillary line. This port has been used to pass a telescope through. At the level of the 3rd and 4th intercostal gaps in the anterior axillary line, two more 3 mL apertures for instrumentation have been placed. After identifying the sympathetic chain, the sympathetic chain resection was extended from the head of the 3rd rib to the head of the 4th rib, extending the resection 2 cm laterally to resect possible chain bypassing branches (e.g., the nerve of Kuntz).

Thoracoscopic sympathotomy technique:

Two ports were used. The first port, containing 5 mL, was introduced in the mid-axillary line's 5th intercostal space; the endoscope was inserted through this port. The other port, a 3ml port, was placed at the anterior axillary line in the 3rd intercostal space under vision. After identifying the sympathetic chain, transection of the sympathetic trunk was done using electrocautery at the level of the 3rd rib and the level of the 4th rib's head, prolonging the cauterization laterally for a length of 2 cm to cauterize possible chain bypassing branches (e.g. the nerve of Kuntz). The other steps were like the technique of thoracoscopic sympathectomy.

Fig. 1: The sympathetic chain dissected, isolated and cauterized.

Statistical Analysis:

The data has been gathered, revised, coded, and entered into the IBM SPSS version 20 statistical package for social science. When the distribution has been found to be parametric, qualitative data has been provided as numbers and percentages, whereas quantitative data has been represented as mean, standard deviations, and ranges. Both groups were compared using an independent t-test and a Chi-square test. If the p-value was < 0.05, it was considered significant.

RESULTS

In this study, a total of forty patients were enrolled, with the average age in group A ranging from 12.05 ± 3.50 years, while in group B it was 12.45 ± 2.98 years. Regarding the diagnostic criteria among all patients, all patients presented by bilateral symmetrical sweat with more than one episode per day and caused them impairment in their daily activity. The age of onset in group A varied from 1 - 10 years with a mean age of 4.6 ± 2.76 years, while in group B, the age of onset ranged from 1 - 9 years with a mean age of 4.65 ± 2.66 years. Ten patients (25%) had a positive family history, 3 from group A and 7 from group B. Concerning age, gender, diagnostic criteria, family history, and age of onset, there has been no significant difference between the two groups (Table 1).

*: Chi-square test;**: Independent t-test

Table 1: Comparison between sympathectomy (group A) and sympathotomy (group B) techniques concerning diagnostic criteria.

The operative time in group A varied from 30 - 78 minutes, with a mean time of 55.65 ± 12.54 minutes, while in group B, the operative time ranged from 30 - 81 minutes with mean time of 45.90 ± 13.71 minutes and that difference was statistically significant (P = 0.024). Regarding intraoperative complications, pneumothorax was developed in one case (10%) in each group (P = 1.00), while minimal bleeding reported in two cases (10%) of group A and one case (5%) of group B (P = 1.0). No cases in our study required conversion to open thoracotomy, showed cardiac complication or Horner`s syndrome (Table 2).

Table 2: Comparison between sympathectomy (group A) and sympathotomy (group B) techniques concerning operative data.

 *: Chi-square test; **: Independent t-test

 In our study, group A had 10% postoperative complications and group B had 25%, with no statistically significant difference between the two groups at one week (P = 0.429). At one month, group A was 10% and group B was 20%, and the difference between both the two groups was statistically insignificant (P = 0.661); at three months, group A was 5% and group B was 15%, and the difference between both the two groups was statistically insignificant (P = 0.605); and at six months, group A was 0% and group B was 10%, with the difference between both the two groups being statistically insignificant (P = 0.526). These complications were in the form of partial failure, pleuritic chest pain and wound infection. There has also been no statistically significant difference regarding recurrence, as it happened in 2 cases (10%) in group B only (P = 0.487). (Table 3).

*: Chi-square test.

Table 3: Comparison between sympathectomy (group A) and sympathotomy (group B) techniques regarding recurrence and postoperative complications.

There was no significant difference regarding degree of compensatory sweating post-operative between the two groups. Sweating as a form of compensation was considered a side effect of the procedure rather than a complication, in our study 70% of each group developed compensatory sweating at all follow up periods and it was ranging from mild to severe degree (Table 4).

*: Chi-square test.

Table 4: Comparison between sympathectomy (group A) and sympathotomy (group B) techniques regarding degree of compensatory sweating post operative.

There was no significant difference regarding postoperative Campos questionnaire between the two groups after one week. While group A showed significant decrease (improvement) regarding postoperative Campos questionnaire than group B after one month, 3 months and 6 months (p=0.033, 0.001 & <0.001, respectively) (Table 5).

*: Independent t-test.

Table 5: Comparison between sympathectomy (group A) and sympathotomy (group B) techniques regarding postoperative Campos questionnaire.

The efficiency was 100% in group A and 95% in group B following one week, while the efficiency decreased to 90% after 1, 3 and 6 months in group B only, without significance between both groups (Figure 3).

Fig. 3: Comparison of postoperative efficiency between the two groups.