The Comparison of VATS Ramicotomy and VATS Sympathicotomy for Treating Essential Hyperhidrosis

Abstract

This study was undertaken to determine if better results could be achieved by comparing the results of a thoracic sympathetic ramicotomy (division of rami communicantes) with a conventional thoracic sympathicotomy (division of sympathetic trunk) for treating essential hyperhidrosis. From August 2001 to February 2002, 29 consecutive patients underwent surgery of the sympathetic nerves in order to treat severe essential hyperhidrosis. Of these patients, a ramicotomy was performed under VATS (VATS-R) in 13 patients, sympathicotomy under VATS (VATS-S) in 13, a unilateral ramicotomy and contralateral sympathicotomy under VATS (VATS-RS) in 2 and a sympathicotomy via a thoracotomy (T-S) in 1. There was no significant difference between the VATS ramicotomy group (VATS-R, n=13) and VATS sympathicotomy group (VATS-S, n=13) in terms of gender, pleural adhesions or comorbidities. However, the age of the VATS-S group at surgery was higher than that of the VATS-R group (p=0.050). The operation times, and hospital stays of the groups were 51.5 and 41.9 minutes, and 2.0 and 2.3 days, respectively. The recurrence rate of the operated sites according to the surgical methods (ramicotomy and sympathicotomy regardless of VATS) was 21.4% (6/28) in the ramicotomy group and 6.7% (2/30) in the sympathicotomy group, but there was no statistical significance (p=0.101). This study compared the dryness of the enervated sites and the severity of compensatory sweating among the ramicotomy (n=11, excluded 2 re-operated cases from 13 VATS-R), sympathicotomy (n=14, VATS-S 13 and T-S 1) and the synchronous or metachronous ramicotomy/sympathicotomy groups (n=4, included 2 reoperated cases of VATS-R). The sympathicotomy group had an over-dryness of the enervated sites (dryness 1.4, from 1 to 3; 1:over-dried, 2:humid, 3:persistent sweating) and complained of severe compensatory sweating (severity 3.5, from 1 to 4; 1:absent, 2:mild, 3:embarrassing, 4:disabling). However, the patients whounderwent a ramicotomy maintained some humidity of the enervated sites (dryness 2.0, p=0.012) and showed milder compensatory sweating (severity 2.7, p=0.056) than those in the sympathicotomy group. Furthermore, the dryness of the ramicotomy side was different from that of the sympathicotomy side in 3 out of 4 ramicotomy / sympathicotomy (R+S) patients (the side of the ramicotomy was humid and that of the sympathicotomy was over-dried). The average dryness and the compensatory sweating at these sites were in the midst of the two groups (dryness and severity 1.6 and 3.0, respectively). A ramicotomy can prevent over-dryness of the enervated area and decrease the severity of compensatory sweating through the selective division of the rami communicantes of the thoracic sympathetic ganglia. Postoperatively, almost all ramicotomy patients had no functional problems in daily life or in their occupational activity, because they could maintain hand humidity. Moreover, they showed no more than a mild degree of compensatory sweating and reported high long-term satisfaction rates. ...

Robot-Assisted Ramicotomy: Evaluation in a Swine Model

“…The optimal technique has remained a subject of controversy because the conventional endoscopic thoracic sympathectomy and sympathicotomy procedures often result in overdryness of the enervated area and irreversible compensatory hyperhidrosis [10]. Criteria for a successful thoracic sympathectomy are: a high rate of hyperhidrosis relief combined with a low rate of recurrence, and a low rate of compensatory and gustatory hyperhidrosis.…”

“…A longer section of the rami communicantes is removed, which includes aberrant connections and sometimes the Kuntz nerve. An additional advantage to this procedure is a residual relative humidity of the hands after ramicotomy, thus avoiding overdryness of the hands [10]. Drawbacks to thoracoscopic ramicotomy are a longer operating time and an increased possibility of accidental injury to the intercostal vessels [11].…”

“…Ramicotomy shows the lowest rate of compensatory hyperhidrosis and the lowest rate of Horner's syndrome [8]. However, a selective thoracic ramicotomy is not easily accomplished by conventional thoracoscopy and questions have been raised concerning the effectiveness of this technique [9,10,11,12]. The DaVinci® three-dimensional optical imaging system enhances visualization and the endowrist technology promotes telemanipulation of soft tissue structures in a relatively inaccessible working space.…”

Estudo da regeneração simpática pós simpaticotomia seletiva experimental (ramocotomia)

“…Infelizmente, o acompanhamento pós-operatório desses pacientes mostrou alta taxa de recidiva da hiperidrose, 5% a 20%, sendo a técnica abandonada pela maioria dos serviços 4,28,62 .…”

“…A principal hipótese que justificaria a recidiva após a ramicotomia nos humanos, que é a de secção incompleta dos ramos comunicantes 28,66,87 . 90,91 .…”