China Clinical Guidelines for Minimally Invasive Treatment of Hand Sweating The National Collaborative Group for Minimally Invasive Treatment of Hand Sweating was established in Fuzhou in March 2009. In accordance with the development needs of minimally invasive treatment of hand sweating in China in recent years, the group was entrusted with the preparation of the “Clinical Guidelines for Minimally Invasive Treatment of Hand Sweating in China” (2009 edition) by the editorial committee based on the latest research results at home and abroad, and on the basis of repeated consultations with experts from relevant disciplines. Hand sweating is a clinical condition caused by disorders of the autonomic nervous system, mainly manifested by involuntary secretion of large amounts of sweat from the palms of the hands due to hyper-secretion of local sweat glands, which seriously affects patients’ life, work and social interaction activities. In recent years, with the development of social economy and people’s pursuit of lifestyle, the disease has become more and more concerned. According to a survey, 3 out of every 1000 people suffer from severe hand sweating disorder. However, nationwide, the awareness rate and consultation rate of hand sweating is still at a low level. Therefore, it is useful and necessary to further increase the awareness and treatment of this disorder. The surgical treatment of hand sweating originated in 1920 when Kotzareff first reported the use of open-heart surgery for thoracic sympathectomy to treat hand sweating, pioneering the use of surgical methods to treat hand sweating. The concept of traditional thoracoscopic thoracic sympathectomy was introduced by Hugh in 1942 and applied in clinical practice. However, it was not widely used because of the complexity and trauma of the surgical approach and method of performing conventional thoracoscopy. It was not until the clinical application of televised thoracoscopic surgery in the 1990s that the ancient procedure of thoracic sympathectomy was rejuvenated and even developed by leaps and bounds. The surgery is no longer massively invasive, but the minimally invasive method of TV thoracoscopy – thoracic sympathetic nerve trunk dissection for hand sweating has obtained good therapeutic results and has been well received and favored by doctors and patients. China is a region where hand sweating is more prevalent, especially in Fujian, Guangdong, Zhejiang and Taiwan. In recent years, China has achieved good results and accumulated more experience in carrying out minimally invasive techniques for the treatment of hand sweating. On this basis, some units have also carried out a series of meticulous clinical research work. The depth of these studies has positive clinical significance for the clinical standardization of surgical methods, avoidance of surgical risks, further improvement of efficacy, and reduction of surgical complications. At the same time, we should also see that there are still many problems in minimally invasive surgical treatment of hand sweating in China that lack a clear understanding, such as the pathogenesis of hand sweating, indications for surgery, the level of thoracic sympathetic nerve trunk dissection and its surgical style, the judgment of surgical results, and the prevention and treatment of postoperative complications such as compensatory hyperhidrosis, which need to be further studied, summarized and improved. Happily, in order to improve the level of hand sweating diagnosis and treatment in China, it was decided by the initiative of all members of the Thoracoscopic Surgery Group of the Thoracic and Cardiovascular Surgery Branch of the Chinese Medical Association, led by Professor Tu Yuanrong of the Department of Thoracic Surgery of the First Hospital of Fujian Medical University, that the National Collaborative Group for Minimally Invasive Treatment of Hand Sweating was established in Fuzhou in March 2009, and the first working meeting of all members was held. This meeting was a successful domestic exchange forum with high level, scale, seminar level and attainment. The experts and professors from more than 20 units across China discussed all aspects of minimally invasive surgical treatment of hand sweating, especially the definition and classification of hand sweating, diagnosis, surgical indications, surgical methods and the prevention and treatment of complications, especially compensatory hyperhidrosis, and made a preliminary consensus. The experts unanimously agreed that minimally invasive surgical methods are by far the most effective way to treat hand sweating, which can well relieve patients’ pain and is a treatment method worth promoting. For this reason, the collaborative group summarized the results of the conference discussions and formed the Clinical Guidelines for Minimally Invasive Treatment of Hand Sweating in China (2009 edition). The editorial committee of the Guidelines hopes that the Guidelines will help medical and health care professionals at all levels to play a standardizing and guiding role in the diagnosis and treatment of hand sweating, and help patients and the general public who are concerned about health to have a correct understanding of hand sweating. It must be pointed out that due to the limited level of the editors, there are still many shortcomings in the Guidelines. Therefore, we sincerely hope that all sister organizations in China will give valuable comments on the Guidelines so that they can be improved in the future. Hand sweating is one of the manifestations of primary localized hyperhidrosis, and patients often have a combination of increased axillary sweating and foot sweating, mainly because of the higher density of exocrine sweat glands in the palms, soles and axillary skin. The epidemiology and incidence of hand sweats Data on the incidence and epidemiological investigation of hand sweats are scarce worldwide. Hand sweating is common in Indonesia, Thailand, and Vietnam in Southeast Asia. In Japan, it is also quite common south of Kyushu and in the Ryukyu region, while such cases are rare in the Hokkaido region. In the United States, Srutton conducted a nationwide survey of 150,000 households in 2004, and the result was a prevalence of 2 or 8%, which attracted widespread attention. In addition, large numbers of cases have been reported from Northern Europe, South America, and the Middle East. The results of a survey conducted by the Department of Thoracic Surgery of the First Hospital of Fujian Medical University in 2004 on 12,803 college and high school students from 20 colleges and universities in Fuzhou City on the prevalence of hand sweating and its associated factors showed that the prevalence of hand sweating was 4,59%, with the prevalence of severe hand sweating being 0,12%, 12 %. Hand sweating usually appears in childhood or adolescence and gradually worsens during adolescence, affecting life and learning. 95.6% of patients have symptoms for the first time at the age of 16, and 15.3% have a family history. The clinical manifestations of hand sweating patients often complain of excessive sweating on the palms of their hands since childhood or adolescence, which affects daily life and work, interpersonal communication, and easily generates avoidance and anxiety. In clinical cases, sweating occurs in several localized areas at the same time, with sweating in the palms, soles, and armpits being the most common, while sweating in the face is rare, and other parts of the body are rare, with common combinations being: palms + soles, palms + armpits, palms + soles + armpits, and other combinations being rare. The appearance of hand sweating symptoms is mostly related to climate, seasons, and many factors such as external temperature, emotional changes, and strenuous activities, but may not have any precipitating factors. The symptoms are sudden and intermittent, with most patients having more severe symptoms in the summer and less severe symptoms in the winter. Hand sweating can also be combined with various skin lesions caused by skin maceration infections of the hands. The diagnosis of hand sweating depends heavily on the history of hand sweating, and the physical examination is usually not positive except for localized sweat secretion. Laboratory tests also generally do not have specific diagnostic value. Therefore, taking a detailed history is an essential step in confirming the diagnosis of hand sweating. The symptoms of hand sweating can have certain triggers, such as mood swings, anxiety, heat, strenuous exercise, etc. However, in many cases, the symptoms can appear suddenly without warning, and the number of episodes varies daily, each lasting 5 to 30 minutes, but the symptoms of hyperhidrosis hardly appear during sleep. The symptoms of hand sweating can be graded clinically, for example, into three levels of hand sweating from mild to severe. Of these, moderately severe patients are the ones with clear indications for surgery. This classification is a guide to clinical diagnosis and treatment. Mild: moist palms; moderate: sweaty palms soaking through a handkerchief; severe: sweaty palms in the form of dripping beads. The diagnosis of hand sweating depends on the detailed history taking. In terms of physical examination, generally only positive signs of abnormal sweating and secondary skin lesions can be found. At the same time, attention must be paid to the detection of some positive signs for the differential diagnosis with secondary hyperhidrosis. For example, wasting may indicate chronic systemic wasting disease, acromegaly may be related to endocrine system disease, and the possibility of hyperthyroidism should be further ruled out in cases of accelerated heart rate, and the possibility of pheochromocytoma should be noted in cases of elevated blood pressure. If necessary, blood and urine tests, blood glucose, blood T3 and T4 concentration measurement and X-ray chest film or chest CT examination can be performed. (2) Diagnostic criteria There are no uniform diagnostic criteria for primary hyperhidrosis. If there is fever, night sweats and weight loss, the possibility of secondary hyperhidrosis should be noted. (3) Differential diagnosis The differential diagnosis process of hand sweating is shown in Figure 1, from which it can be seen that many diseases have clinical manifestations of hyperhidrosis, either generalized or localized hyperhidrosis may be just some symptoms of a certain disease. Therefore, a correct diagnosis can only be made by an in-depth and detailed history as well as a detailed physical examination. Especially for patients who need further surgery, a series of identification and exclusion are necessary. Thoracoscopic thoracic sympathectomy I. Indications for surgery: 1. Moderate and severe cases that have been clearly diagnosed; mild cases do not need to be considered for surgery. 2. Severe head and facial hyperhidrosis, sympathetic muscular dystrophy, ischemic upper limb syndrome such as Raynaud’s disease, advanced pancreatic cancer cancer pain, long QT syndrome, limb red pain, etc. can also be treated by thoracic sympathectomy. 3.It is recommended not to perform two simultaneous surgeries, such as additional pulmonary alveolar and pulmonary nodule resection. 4. The age of pediatric surgery is recommended to be above 10 years old, and the family and their children have a strong desire for surgery. Contraindications to surgery: Patients with secondary hyperhidrosis, severe bradycardia, pleural adhesions, pleural hypertrophy and previous history of thoracic surgery should be considered as contraindications to surgery, and those with neuroticism should preferably not perform surgery. Pre-surgical preparation 1. Pre-operative diagnosis of hand sweating should be made clearly and relevant examinations should be performed to exclude hand sweating symptoms secondary to other diseases. 2. Preoperative routine examinations include X-ray chest radiographs or CT scan of the chest, electrocardiogram, and routine laboratory tests such as hematology or immunology and a full set of clinical biochemistry. 3.Recent upper respiratory tract diseases such as cold, cough, fever, gastrointestinal discomfort such as nausea and vomiting, diarrhea and other unexplained discomfort should delay the surgery. 4.Pediatric trachea is thin, X-ray chest radiographs should be made routinely before surgery to select the appropriate type and size of tracheal intubation. Surgical techniques and methods 1. Anesthesia: According to the actual situation, choose double-lumen intubation, single-lumen intubation, laryngeal mask or mask ventilation anesthesia. Ventilation can be stopped during surgery so that the lung tip is in natural collapse. Close monitoring of pulse, heart rate and oxygen saturation, if the oxygen saturation decreases to below 90%, the operator immediately stops the operation, wait for the oxygen saturation of the expanded lung to rise to 95-100%, and then stop ventilation again for surgical operation. 2.Position: Generally, 30°~45° supine, upper arm abducted to 90° with chest wall and fixed on the hand frame to expose bilateral axillae. 3. Incision: A 1.0 cm incision is made in the 5th intercostal space in the mid-axillary line, and a 5mm 0° or 30° thoracoscope is inserted after the Trocar is inserted, and the anesthesiologist is asked to stop ventilation. The choice of incision location and size can also be adjusted by the operator according to his own experience and habits. 4.Operation: After entering the thoracic cavity, the thoracoscope first identifies the anatomical structure of the upper thorax. Since the first rib is often covered by soft tissues such as yellow fat pad, the second rib is clearly visible at the apex of the thorax, and the sympathetic nerve stem is located at the lateral side of the rib cranium, which is white in color, and is only 2-3mm in diameter when magnified under the microscope, and can be perceived by lightly touching and sliding with the electrocoagulation hook. The corresponding nerve trunk was cauterized by electrocoagulation on the surface of the 3rd or 4th rib. In order to eliminate the presence of Kuntz bundles and traffic branches, a further 2-3 cm of cautery can be extended laterally on the surface of the rib. After the operation, the field is carefully checked for active bleeding, and after confirming that the palm temperature rises 1-2°C, the anesthesiologist is instructed to expand the lung under thoracoscopic surveillance, withdraw the thoracoscope and suture the incision, and place a thin 16F tube in the other incision, with one end extending into the roof of the chest and the other end placed in water outside the chest, and then withdraw the tube after the anesthesiologist has sufficiently exhausted the lung and suture the second incision. After the operation on one side, the opposite side is operated on, and the procedure is the same. As long as the hemostasis is complete and no damage to the lung tissue occurs, it is not necessary to leave a chest tube in place. The above is a two-hole procedure, but a single-hole thoracoscope, a TV mediastinoscope, or a “Y” pleural biopsy scope can also be used. All three lumpectomy tools are used to perform intrathoracic surgery through a skin incision 2-4 cm long (one-hole approach). The anesthesia and surgical approach are the same as described above. The choice of anesthesia and lumpectomy can be made by the operator according to his conditions, equipment and experience, and there is no need to make rigid rules. The main methods of thoracoscopic sympathetic nerve surgery in the upper thoracic region are excision, resection, and branching excision. The method of blocking the sympathetic stem can be electrocoagulation cautery, titanium clip closure, or ultrasonic knife cut, we recommend the simple and effective electrocoagulation cautery as the first choice, the latter two methods are more complicated, the effect is also not ideal, should not be promoted. The surgical cutting plane has not yet been unified, but advocates a single cut, not advocate multi-sectional cut, except for the head and face sweating, must retain T2. Intraoperative and postoperative monitoring 1, palm temperature monitoring: preoperative palm thermometer, and connected to the anesthesia machine display, pay attention to palm temperature changes and repeated bilateral comparison. The hand temperature before thoracic sympathetic nerve dissection is generally between 25℃~28℃, some even can not be measured, if the hand temperature is high can be artificially performed palm local physical cooling to below 30℃. The palm temperature rises quickly after the nerve is cut, and when the palm temperature rises rapidly by 1-2℃ or more, it can be considered effective, which can be used as one of the important reference bases for intraoperative nerve block. If the palmar temperature never rises, it is recommended to cut off T2 decisively to prevent the presence of the traffic branch or cut off incompletely after the problem. 2, the patient’s heart rate (rhythm) and blood pressure changes should be noted during the operation, monitor the oxygen saturation. 3. Individual patients may have transient respiratory distress after extubation after surgery, and may continue to receive oxygen in the resuscitation room for observation. 4.After returning to the ward, we should monitor the electrocardiogram and oxygen saturation until the next day. Intraoperative bleeding Intraoperative bleeding is usually an injury from the intercostal vein or the branch of the odd vein when separating the thoracic sympathetic chain, but there is also bleeding from the trocar into the chest, including tearing of the intercostal vessels. The right thoracic sympathetic T3 or T4 nerve trunk is closer to the branch of the odd vein, and its surface is often crossed by small longitudinal and transverse claw-like veins. Another method is to use the electrocoagulation hook on one side of the nerve stem to push the nerve stem to the other side with slight force, rotate while electrocautery, also can pick out the nerve stem, once bleeding, do not panic and blindly cauterize electrocoagulation, should immediately use endoscopic forceps clamp electrocoagulation to stop bleeding, or clip small gauze ball compression to stop bleeding, generally can be successful. 2, cardiac arrest In the literature, there have been individual reports of intraoperative cardiac arrest or postoperative severe bradycardia requiring pacemaker maintenance, therefore, we must be vigilant when performing this procedure, especially when doing the left sympathetic nerve chain severing surgery, because this side is the dominant side of cardiac innervation, severing may have a certain effect on the heart rate, so the surgery should be performed on the right side first. The patient’s heart rate (rhythm) and blood pressure should be highly monitored during the operation. However, most studies have concluded that the effects of the procedure on the cardiovascular system, although present, are generally minimal. 3.Pneumothorax Up to 75% of patients have a small amount of gas remaining in the chest after surgery, but it can usually be absorbed, and only 0.4-2.3% of patients need to place a chest drain to vent the air. The common causes of pneumothorax are: direct injury to lung tissue when trocar enters the chest, tearing of the pleural roof when the lung is atrophied, and rupture of the original pulmonary blister at the tip of the lung when the lung is expanded. As thoracic sympathectomy is generally not routinely done for thoracic cavity flushing, lung rupture leakage is more difficult to be detected, if the gas is found to be incomplete when exhausting after surgery, chest drainage should be placed. 4, subcutaneous emphysema can appear alone or with pneumothorax, its incidence is 2, 7%. It usually appears around the incision and is confined to the chest, and it is quite rare to involve the mediastinum, retroperitoneum, or even the scrotum. Mild subcutaneous emphysema usually does not require treatment, but attention is drawn to the presence of a combined pneumothorax, while severe subcutaneous emphysema mostly requires placement of subcutaneous drainage. 5.Pulmonary atelectasis or pneumonia Postoperative X-ray of individual patients suggests segmental pulmonary atelectasis or pneumonia, the main points of prevention and treatment are thorough pulmonary exhaust after surgery, early postoperative bed activity, more deep breathing and back patting, coughing sputum. 6, postoperative transient palm sweating: transient sweating occurs within a week after surgery, and is characterized by more severe or similar symptoms of palm sweating after surgery than before surgery, appearing at any time of the day or night, lasting from a few minutes to several hours, and recurring several times a day, without any causative factors, and resolving itself after a week. The mechanism is not known, but it may be due to a possible “sensitization” or “rebound” of the effectors within 1 week after the sweat glands are de-sympathetically innervated, resulting in overproduction of sweat glands. Patients should be informed before surgery, otherwise they may be concerned about the failure of the procedure. It is the most common complication after sympathetic nerve surgery in the upper thoracic region. The mechanism of occurrence is unknown, and it mainly manifests as a significant increase in sweating in one or more parts of the body not innervated by sympathetic nerves, such as the chest, abdomen, back, buttocks, thighs and calves, compared to the preoperative period. The causative factors are mainly high temperature or after activity, and about 3-5% of patients may be related to emotional excitement or mental tension. The incidence is about 70-80%, and severe cases are not rare. The grading criteria of postoperative compensatory hyperhidrosis can be referred to Table 6. Most patients can tolerate and improve more easily after a period of adaptation and psychological adjustment, and it does not affect the quality of life after surgery, but there are still about individual patients who may cause discomfort and life disturbance as a result, which is the main reason for patient dissatisfaction after treatment. Therefore, how to prevent and alleviate postoperative compensatory hyperhidrosis has become one of the main topics in the treatment of hand sweating in recent years. The incidence of compensatory hyperhidrosis after traditional T2-4 sympathectomy is as high as 28,9-98%, and thus the procedure has been abandoned. In recent years, it has been reported that preservation of T2 and single severance of T3 or T4 sympathetic nerve can greatly reduce its incidence. 2, gustatory sweating: manifested as sweating when smelling special fragrance or eating spicy food, the incidence of which varies from 1% to 56%. The mechanism is unknown. 3. Postoperative relapse: It occurs mostly 6 months to 2 years after surgery, and the symptoms of postoperative relapse are generally milder than those before surgery. Its incidence is about 1% or less, and it is presumed to occur because the intraoperative sympathetic nerve resection is not complete, and there are still side branches or variant branches left behind, especially the kuntz nerve unexcised nerve regeneration nerve variant, which may be related to the innervation of T1 thoracic sympathetic nerve. Intraoperative monitoring of palm skin temperature can determine the completeness of sympathectomy and should be used routinely. For postoperative recurrence in first surgery cases with preserved T2, reoperation to cut T2 is recommended for treatment. 4, Horner’s syndrome: manifested as eyelid ptosis, eye entropion, pupil narrowing, and no sweating on the injured side, is one of the most serious complications of sympathetic nerve surgery in the upper thoracic segment, mainly caused by heat conduction waves to the stellate ganglion during cautery cutting of the sympathetic nerve trunk. The incidence of this complication in conventional T2 sympathetic surgery is also less than 1%. With the use and development of television thoracoscopy, improved surgical methods and the experience of physicians, this complication is very rare, especially in recent years since T3 or T4 sympathetic nerve surgery for hand sweating. Most cases of Horner syndrome can heal spontaneously with time. The stellate ganglion is covered by a yellow fat pad that can be used as an intraoperative identification marker and care should be taken not to damage it. Postoperative follow-up of thoracic sympathectomy Sympathetic trunk dissection of the upper thoracic segment has become an effective and durable treatment for hand sweating, but the answer to the questions of how, where, and to what extent the procedure is performed is not uniform; whether the removal of sympathetic causes some potential risk of cardiac and pulmonary function; and the effect of the surgical approach on compensatory hyperhidrosis will require long-term follow-up. Therefore, it is necessary to establish a complete set of follow-up data. All surgical patients should have a complete medical history and contact method before follow-up, as well as a complete surgical record, especially the sympathetic stem procedure, scope and location should not be omitted, and should be followed up every 1 month, 6 months and 1 year after surgery, and then once a year in outpatient clinic or by telephone, or a tabulated questionnaire can be conducted. The follow-up includes: ① the improvement of hand sweat, foot sweat, axillary sweat and skin disease regression after surgery; ② recurrence: time, degree, trigger, site, aggravating or relieving factors; ③ the quality of life after surgery compared with the preoperative situation, satisfaction with the surgery; ④ compensatory sweating situation: time, degree, trigger, site, aggravating or relieving factors; ⑤ any other complications, etc. (Attachment of hand sweating follow-up questionnaire) Preoperative talk or information Thoracoscopic thoracic sympathetic nerve stem dissection is the only effective minimally invasive treatment for hand sweating. More and more patients are requesting surgical treatment because of the mature surgical technique, mini cosmetic incision, significant surgical effect, few complications, quick postoperative recovery, short hospital stay and relatively economical cost. However, we must be aware that any kind of surgery has both advantages and disadvantages. Although this surgery is satisfactory to more than 98% of patients after surgery, there are still very few patients who are not satisfied and even regret the surgery. One of the main reasons for this is the common postoperative side effect of compensatory hyperhidrosis, where the “de-sympathetic” areas (such as the trunk or lower extremities) are more sweaty than before surgery. This phenomenon is also called metastatic hyperhidrosis, and although the mechanism of its occurrence is unknown, recent practice has shown that preserving T2 can greatly reduce the incidence of compensatory hyperhidrosis. Therefore, the preoperative conversation should focus on the following: 1. Regarding compensatory hyperhidrosis: some patients may develop metastatic hyperhidrosis after surgery, which is a common phenomenon, mostly to a lesser extent, and uncommon in severe cases. There is no ideal method to eliminate it, only psychotherapy, but the symptoms may gradually decrease with time. For this, patients must be fully prepared psychologically. 2, about post-operative relapse: post-operative relapse is very rare, the main reason may be due to nerve walking variation, for this case can be re-operated to cut off T2 to obtain a cure. 3, about axillary sweating and foot sweating: axillary sweating and foot sweating is also a local manifestation of hyperhidrosis. After the thoracic sympathectomy, some patients do have axillary sweating and foot sweating disappeared or reduced, but there are patients who do not relieve or even aggravate, which should also be explained. 4, about fox odor: this is the axillary sweat gland overdevelopment of an abnormal odor of body fluids, the thoracic sympathetic nerve cut may reduce sweat, but can not be cured, this point should also be explained. 5, about head sweating: surgery must be cut T2, after surgery may occur severe head and facial sweating and serious transfer compensatory hyperhidrosis, the operator and the patient must be cautious. 6, about the red face (social phobia): it is not necessarily a disease, the main clinical manifestations of a certain situation, the natural occurrence of shyness, timidity, restlessness, head and facial skin reddening and sweating and other phenomena. Some foreign people use thoracic sympathectomy treatment, received a certain effect, but the recurrence rate is quite high, this case should be the main psychological treatment, should not blindly implement surgery.