TV thoracoscopic sympathetic nerve chain dissection – a safe and effective minimally invasive technique for the treatment of excessive sweating on the head and face, hands and axillae.
The incidence of hyperhidrosis and its impact on the quality of life of the population
Hyperhidrosis, especially in exposed areas of the body such as hands, armpits and head and face, seriously affects the normal life of many people. In fact, it is often a pathological condition, medically known as “hand sweating”, “head and face hyperhidrosis” or “axillary sweating”. It seriously affects the quality of life of this group of people. Due to nervousness or noisy head and face sweating and afraid to show their heads in public social occasions, afraid to give a speech on stage; due to severe sweaty palms and afraid to shake hands with others, or ashamed to hold hands with lovers; armpit sweating wet clothes make young girls embarrassed; writing sweat wet paper; operating the computer sweat wet keyboard; …… all these are These are the woes of such friends. It can be said that the sweating of these exposed parts seriously affects their emotions, social life, career choice and even marriage. Especially in recent years, as people’s standard of living has improved and their quality of life has increased, more and more people are seeking medical attention for this condition.
There are no exact statistics on the incidence of hyperhidrosis in the Chinese population. A foreign population-based statistic shows that the prevalence of various degrees of hyperhidrosis in various areas is between 6 per 1,000 and 10 per 1,000. Of these, 1/4, or 1.5 to 2.5 per cent, are hyperhidrosis of the hands. Forty percent of patients with hyperhidrosis have a genetic predisposition.
Traditional treatment of hyperhidrosis
Most cases of hyperhidrosis have no clear cause unless there is a clear underlying condition such as hyperthyroidism, excessive obesity, or neurosis that can be accompanied by hyperhidrosis. Because the pathogenesis of hyperhidrosis is unknown, there are a variety of treatments for hyperhidrosis. Traditional treatments include biofeedback, hypnotherapy, psychotherapy, sedation, anticholinergic receptor drugs, Chinese herbal medicine, topical astringent treatment of the skin at the sweating site, or radiation therapy. However, all these treatment methods do not have very certain therapeutic effects. The long history of unsatisfactory treatment results has led many people to fear and various incorrect interpretations of this condition. Some people believe that it is a genetic problem that cannot be treated; others believe that it means that they are “weak” and take a lot of “supplements” for this reason, but in the end, it does not help; others believe that it is because they are introverted and timid. Some people think it is because they are introverted and timid, so they appear to be sweating profusely when they get to the lectern or other public places. Whether or not this is true, it does add to the psychological burden of these sweaty friends.
The history of sympathectomy and the current status of its implementation in Japan and abroad
Sympathectomy was first used in 1920 to treat hand sweating. Due to the special anatomical location of this structure, the surgery could only be done by open-heart surgery, which was obviously very traumatic. Therefore, this method was not widely accepted by patients and physicians at that time. However, since this procedure of removing the sympathetic nerve chain did provide a definite treatment for excessive sweating of the hands, the procedure was not abandoned, and the quest to improve it and make it more minimally invasive began. The supraclavicular incision, paraspinal incision, axillary incision, etc. have been invented, but they have not significantly reduced the surgical trauma, but rather increased a series of possible surgical complications. It has also been proposed to treat hand sweating by disrupting the sympathetic nerve chain through extracorporeal injection of some special drugs. Although this approach is much less invasive, an important problem is that the efficacy is very uncertain, because it is difficult to accurately reach the desired nerve segment by extracorporeal puncture.
The advent of televised thoracoscopic techniques in the 1990s gave a light in the darkness to the exploration of this surgical approach. This is a modern medical technology based on television imaging and cold light source technology. Through a small 0.5 cm incision in the chest wall and a TV thoracoscope placed in it, the surgeon can clearly see the sympathetic nerve chain located in the paraspinal column, and through another small incision of the same size and some special instruments, he can perform the procedure of removing or cutting the sympathetic nerve chain.
The technical simplification of this procedure, made possible by modern technology, has led to a tenfold or even a hundredfold increase in the number of cases performed worldwide in the last decade or so. In the last few years, more than 200 articles have been published annually on this procedure, involving thousands of cases. In Taiwan, in particular, many hospitals and physicians have accumulated experience in thousands or even tens of thousands of sympathetic chain resections for hand sweating, making it the most thoroughly studied procedure in the world. The use of televised thoracoscopic techniques has made this procedure a truly mature and routinely performed technique.
Along with the improvement of minimally invasive surgical methods, the indications and technical details of the procedure have also changed a lot. For example, it was previously thought that this procedure could only treat hand sweating, but now it has been found that axillary sweating, neck and head and facial sweating can also be treated with this procedure. In particular, the head and facial sweating, which used to be considered a forbidden area for surgical treatment, is now routinely treated overseas; while it used to be thought that a certain segment of the sympathetic nerve chain had to be removed to achieve treatment, it is now found that cutting or even clamping the nerve chain can also achieve treatment. The severing procedure has completely replaced resection as the current standard procedure.
The basic approach of TV thoracoscopic sympathectomy and the problems associated with it
Patients need a short hospital stay of 2-3 days to undergo the necessary tests before surgery. General anesthesia is used for the procedure. The patient is placed in a semi-supine position with the upper body slope sitting up. The surgeon stands on the patient’s side and first makes a small incision about 0.5 cm long in a concealed location under the axilla of the chest wall. A thoracoscope is placed inside and the surgeon can see the thoracic cavity and the sympathetic nerve chain located next to and parallel to the spine on a television screen. Through another small incision in the chest wall of similar size and some special instruments, the sympathetic chain can be cut in about 5 minutes. After the surgery on one side, the other side is operated on using the same approach. The total operation time is less than half an hour. The patient is able to move around the same afternoon after the surgery. The patient can be discharged the next day. The patient can go back to work within a week at the most. There is basically no scarring on the chest wall after the wound is removed. Even if there is some scarring, it will not affect the aesthetics because it is located in a hidden location like under the armpit.
Surgical effectiveness, safety and possible complications.
The improvement rate of hand sweating can reach 98%-100%, and the improvement rate of head and face hyperhidrosis is over 95%. The procedure is generally safe because it is very minimally invasive. The most frequent complication is compensatory sweating in other parts of the body, but less than 10% of patients with this condition are bothered by it or regret the procedure. In addition, some patients experience a slightly slower heart rate during surgery, but this does not usually interfere with normal life or physical activity. Horner’s syndrome is a frequent complication in the past, and one of the most obvious symptoms is postoperative eyelid ptosis. This complication has been minimized with the use of TV thoracoscopy. And if postoperative ptosis does occur, it is mostly a transient problem that recovers gradually.
Social and medical factors influencing the choice of this procedure
Although this procedure has been available since the 1920s, it has not been widely used historically, mainly because of the high level of surgical trauma, and since the 1990s it has been increasingly reported and accepted by more and more people as a result of the radical solution to the problem of surgical trauma with televisual thoracoscopy and the increased demand for quality of life. But even so, there are still many people suffering from excessive sweating who cannot undergo such a procedure in time. There are a number of social and medical factors:
1. Due to the traditional concept, many people do not know that excessive sweating of the hands and head is a separate and thoroughly treatable condition, so they “suffer in silence” for a long time without going to the clinic for treatment.
Many patients with hand sweating or head and face hyperhidrosis do not know which department they should go to for treatment, and often the first department they think of is dermatology, neurology or internal medicine, and the doctors in these departments often do not know about sympathetic nerve chain severing surgery, making it impossible for these patients to receive timely and accurate treatment.
3. Thoracic surgeons are the only competent doctors to perform this procedure, but most patients, even those who know about this procedure, do not know that they should seek treatment for diseases like hand sweating and head sweating from a thoracic surgeon. So on the other hand, for these thoracoscopists, they often have very little access to patients with this type of hyperhidrosis.
This situation of “patients not finding the right doctors and doctors not meeting the right patients” is the main bottleneck that limits the widespread use of this procedure. This also illustrates the importance of media publicity for this surgical procedure and this condition. In a sense, hyperhidrosis is a new disease that people encounter in modern society to improve the quality of life and social life after meeting the basic needs of survival; and TV thoracoscopic sympathetic nerve chain dissection is a new technology that emerged after the improvement of traditional surgery by modern technological progress, how to let this new problem be solved by this new technology, i.e., how to let modern people who are interested in improving their quality of life benefit from modern technology. It is the important duty of the science popularizers and the media to benefit from this new technology.