Discussion:
Currently, thoracoscopic sympathectomy (TS) is accepted as a standard
treatment technique for PH. This minimally invasive approach has many
benefits include reducing postoperative pain, shorter hospitalization,
earlier recovery and return to work, and fewer complications. Both sides
can be treated in the same sitting, thus avoiding readmission for a
second procedure for the opposite side. [10]
The thoracoscopic approach allows clear delineation of the sympathetic
chain and the ganglia including the collateral branches (Kuntz’s
nerves). Better visualization of the stellate ganglion and its
preservation to avoid development of post-operative Horner’s syndrome.
[11]
As noted in many studies, the plantar domain affects considerable part
of those patients of about 45% [4]; while others reported incidence
of plantar domain of 70 to 100 % of patients with primary
hyperhidrosis; latter researchers used extended technique of ablation
from R3 to R12 to manage those cases [12]. In the Society of
Thoracic Surgeons 2011 Expert Consensus for the Surgical Treatment of
Hyperhidrosis [13], no recommendations for plantar domain management
were noted. All of that arouse us to study such group of plantar
hyperhidrosis patients with less invasive technique searching for
acceptable outcome.
Our study included 213 patients diagnosed as primary hyperhidrosis and
managed by DOTS approach. They had immediate improvement of
hyperhidrosis without any mortality. There was no need for the placement
of ports in any patient, and no conversion to open thoracotomy in our
series.
Mean BMI in our study was 23.1±2.9 going similarly with Wolosker n. et
al. [14] study who reported mean BMI of 20.6±3 and 21.9±2.55 for
their adolescent and adult groups. Repeatedly, different studies
reported that results will not be satisfactory in patients with higher
BMI, because of an increased prevalence of severe CH has been
demonstrated in patients with a BMI higher than 25 [15]. Miller DL.
et al. [16] in their study including 282 patients found that
increased BMI was associated with increased in CH. They explain this as
heavier patients usually experience total body excessive sweating,
rather than sweating in isolated areas. Patients with higher BMI have
more difficulty with their thermoregulation. Again, Ishy A. et al.
[17] in their Study including 40 patients found that individuals
with a BMI more than 25 are predisposed to have a higher incidence of
CH.
Using the HDSS scoring for selecting patients, the patients scored 3
were 55.4% of study patients and those scored 4 were 44.6%.
Postoperatively, at one-year follow-up, dramatic improvement of
patients’ QoL was achieved; the severity score changed to 97.2% mild
(score 1 in 93.9% and score 2 in 3.3%) and 2.8% moderate to severe
(score 3 in 1.9% and score 4 in 0.9%). This was quite the same as
Kuijpers M. et al. [18] in their study including 100 patients with
bilateral thoracoscopic sympathectomy who reported mean HDSS score
pre-operative of 3.69±0.47 and mean post-operative HDSS of 1.06±0.34
showing significant improvement. This throughout repeated studies
proving that TS is an effective line in management of PH with improved
QoL.
Despite that dramatic improvement in quality of life, we noticed the
occurrence of compensatory hyperhidrosis. It manifests as excessive
sweating in different areas of body appearing later after completely
free interval of any excessive sweating. In our study, most of them were
after 6 months; its overall incidence was 35.7% of patients. This is
still the most common late complication, although its mechanism is still
unclear. Our incidence of CH was lower than Prasad A. et al. [19]
who had 63% post-operative CH after R3 resection; but it was higher
than Ibrahim M. et al. [20] who reported 19% of their patients with
CH. Their patients showed a gradually decreasing intensity over the
follow-up period; they also resect from R2 to R4.
The DOTS procedure required operative time ranging 20-45 minutes with
mean 35.03±4.1 minutes. Nearly, Ibrahim M. et al. [20] noted in
their study of 260 patients who had single stage bilateral thoracoscopic
sympathectomy a mean operating time of 38±5.0 minutes. On the other
side, Kuijpers M. et al. [18] got a mean operative time of 74±12
minutes for a bilateral sympathectomy; they used to perform their
operation in lateral decubitus position, so more time was consumed in
patient repositioning. When they shifted to beach chair position, they
could perform the surgery on both sides without need for repositioning.
This modification saved more time and showed significant reduction in
their operation time to 47±18 minutes (p <0.001).
Post-DOTS pain was simple, it required only oral paracetamol or NSAIDs.
No patient needed morphine. The DOTS approach causes less postoperative
pain as post-thoracoscopic pain is usually related to the trauma of the
thoracic wall caused by introducing the trocars into the intercostal
space and periosteal injury.
On the interesting comparison of palmo-plantar patients to palmar ones,
we found comparable groups with no significant difference regarding age,
sex distribution, preoperative HDSS score, operative time, pneumothorax
or recurrence.
Mean hospital stay was 35.23±21.14 hours in palmar group. It was
significantly longer than palmo-plantar group mean of 25.96±4.46 hours
(p= 0.001); that may be due to higher rate of pneumothorax (4.5%) and
ICT insertion (1.5%) in the palmar group.
Regarding CH, it was not significant between the two groups with 34.4%
in palmar group and 38% in palmo-plantar group. Moreover, its
distribution was not significant; the trunkal region was more affected
followed by plantar region.
Precisely, the plantar CH was 12.7% in palmar group, which is nearly
like 16.5% in palmo-plantar group. This finding enforced the
possibility that patients with palmo-plantar hyperhidrosis would benefit
from DOTS. Also, the postoperative plantar hyperhidrosis, reported in
many previous studies as miserable recurrence with failure rates of
36-44% [21], may be just redistributive acceptable CH; if it occurs
similarly in patients with different types of hyperhidrosis
postoperatively.
At last, the overall outcome was satisfactory with patients HDSS score
at one-year follow up of stage 1 in 94.8% of palmar group patients and
92.4% of palmo-plantar ones. Even with incidence of CH, it still
affects the quality of life less than PH, as it is mild and much less
affecting the professional or social life of the patients.