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.