By Martin Cooper, MD
But oh, what a clammy hand his was! As ghostly to the touch as to the sight! I rubbed mine afterwards, to warm it, AND TO RUB HIS OFF. It was such an uncomfortable hand, that, when I went to my room it was still cold and wet upon my memory.
- Charles Dickens from David Copperfield
Thermoregulation is assisted by sweat mechanisms of the human body. Hyperhidrosis is a condition of excessive sweating of the hands, feet and occasionally, the axillae. This type of sweating does not appear to benefit the body's regulatory system. Though not life threatening, this condition can cause severe social embarrassment and occupational difficulties.
My experience with hyperhidrosis spans 30 years. During this period, the genetics, epidemiology and treatment methods have been investigated. While the exact etiology remains unknown, some researchers believe that it is related to an overactive sympathetic nervous system. But again, the cause remains an enigma. The incidence of this worldwide disorder is also not truly known, with reports stating it to be between 1% and 2% of the general population. The gender incidence is approximately the same. Individuals with this condition have been seen between the ages of one month and 71 years of age. There does not appear to be any regression with aging. Though no specific genetic pattern has been determined in our series, there is an approximately 40% familial incidence.
Individuals with this condition present with findings of excessive sweating of their hands, feet, and occasionally, the axillae. The diagnosis is made only with a history and physical examination. Teenagers as well as older individuals will stress how devastating the condition is to all aspects of their life.
Many of these individuals have tried difference medical modalities involving drying agents, anticholinergic drugs, iontophoresis, radiation therapy, botulinum toxin, beta blockers, biofeedback, acupuncture and hypnosis; all of these modalities having limited or temporary success, and none proving curative.
The most definitive "curative" procedure has historically been surgical sympathectomy. More than 2,000 sympathectomies have been performed at Cedars-Sinai Medical Center. Almost half of these patients underwent an open posterior approach with resection of the sympathetic chain and T2 and T3 sympathetic ganglia. Though the outcomes were excellent, it was a painful operation for the patient, with a several-day hospitalization, and an extended convalescent period.
Because of this, Dr. Richard Fischel and I developed an outpatient procedure consisting of a minimally invasive, video-assisted thoracoscopic operation that could duplicate the results of the open procedure without the prolonged convalescence and significant discomfort.
This minimally invasive procedure is carried forth in the prone position after single lumen intubation. Two separate 5 mm incisions are made on each side of the thorax, and with a 30-degree thoracoscope, CO2 insufflation and the Harmonic Scalpel(TM), the sympathetic chain and the T2 and T3 ganglia are removed. The T4 ganglia is included for axillary sweating.
The age of the patients included in the VATS (video-assisted thoracoscopic surgery) procedure range from 11 to 69, with 100% relief of palmar hyperhidrosis. There has been no operative mortality and essentially no operative morbidity. The overall percentage of Horner's syndrome in our large series is basically nonexistent. The overall incidence in the world literature is 1 to 3%. Chest tubes are not employed as part of the procedure. The Harmonic Scalpel is used for resection of all neural elements. The entire operative procedure usually lasts no more than 30 minutes.
Excellent results are obtained for axillary sweating when the T2-T4 ganglia resection occurs. Foot sweating is decreased in at least 50% of the operated cases. Facial sweating is also substantially diminished.
Side effects include self-limiting chest discomfort, gustatory sweating, and more importantly, compensatory sweating. Complaints of facial sweating related to food or liquid ingestion is small (<1%). The percentage of compensatory sweating which generally includes moisture on the chest below the nipple line, back, back of legs, or pelvis ranges in the literature from 17% to as high of 70%.
Our series is significantly lower with only 1 to 2% having severe compensatory sweating, and those patients regretted their decision for the operation. The remaining approximately 98% have found the procedure to be a life-changing experience.
Essential hyperhidrosis is a very personal disorder. Only sufferers of this ailment know what it is like to awaken each morning hoping that his or her profuse sweating has ceased. Fortunately the minimally invasive VATS procedure has enabled patients to enhance the quality of their lives.
Martin Cooper, MD is Director of the Hyperhidrosis Center in the Division of Neurological Surgery at Cedars-Sinai Medical Center in Los Angeles.
1. Fischel R., Cooper M., Kramer D. Microinvasive resectional sympathectomy using The Harmonic Scalpel(TM). A more effective procedure with fewer side effects for treating essential hyperhidrosis of the hands, face or axillae. Clin Auton Res (2003) 13 (Supple) 1/66-1/70.
2. Fischel R., Cooper M. Microinvasive VATS sympathectomy for hyperhidrosis. Surgical Rounds (June 2001).
