Abstract
Background
Many techniques have been used to treat palmar hyperhidrosis. Compensatory sweating is a difficult adverse effect. Clipping has been proposed because of its supposed reversibility when clips are removed at a later date. The primary aims of this article are to investigate the neuronal lesion of the sympathetic chain caused by clipping and to study the possibility of regeneration after removal of the clips.
Methods
We performed an experimental study at the Minimally Invasive Surgery Centre Jesus Uson in Caceres (Spain). We used a swine model, performing clipping, unclipping, and extirpation of different segments of sympathetic chain with clips and after clip removal, following a chronogram of 10, 20, and 30 days. Pathologic studies of specimens and statistics were done at the University of Seville.
Results
Ten days after clipping, all sympathetic chains displayed evident Wallerian degeneration. Twenty days after clipping, Wallerian degeneration of myelinated fibers was more widespread and also more striking. Thirty days after clipping, a very marked macrophagic reaction was visible, with multiple signs of phagocytosis of myelin debris. By 30 days post operation and 20 days after clip removal, a few residual myelin and amyelinated fibers were visible. These findings suggest that axon regeneration is not possible.
Conclusions
There are Wallerian degeneration and axon loss 10 days after clipping. The almost total absence of myelinated and amyelinated fibers following clip removal suggests that there was no nerve regeneration, and that therefore clipping cannot be considered a reversible technique.
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References
Malmivaara A, Kuukasjarvi P, Autti-Ramo I (2007) Effectiveness and safety of endoscopic thoracic sympathectomy for excessive sweating and facial blushing: a systematic review. Int J Technol Assess Health Care 23:54–62
Hamm H, Naumann MK, Kowalski JW, Kütt S, Kozma C, Teale C (2006) Primary focal hyperhidrosis: disease characteristics and functional impairment. Dermatology 212:343–353
Strutton DR, Kowalski JW, Glaser DA, Stang PE (2004) US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol 51:241–248
Loscertales J, Arroyo Tristan A, Congregado Loscertales M, Jimenez Merchan R, Giron Arjona JC, Arenas Linares C, Ayarra Jarne J (2004) Thoracoscopic symapthectomy for palmar hyperhidrosis. Immediate results and postoperative quality of life. Arch Bronconeumol 40:67–71
Rodríguez PM, Freixinet JL, Hussein M, Valencia JM, Gil RM, Herrero J, Caballero-Hidalgo A (2008) Side effects, complications and outcome of thoracoscopic sympathectomy for palmar and axillary hyperhidrosis in 406 patients. Eur J Cardiothorac Surg 34:514–519
Lin CC, Telaranta T (2001) Lin-Telaranta classification: the importance of different procedures for different indications in sympathetic surgery. Ann Chir Gynaecol 90:161–166
Whitson BA, Andrade RS, Dahlberg PS, Maddaus MA (2007) Evolution of clipping for thoracoscopic sympathectomy in symptomatic hyperhidrosis. Ann Thorac Surg 84:1059–1065
Lin CC, Mo LR, Lee LS, Ng SM, Hwang MH (1998) Thoracoscopic T2-sympathetic block by clipping—a better and reversible operation for treatment of hyperhidrosis palmaris: experience with 326 cases. Eur J Surg 580:13–16
Moya J, Ramos R, Morera R, Villalonga R, Perna V, Macia I, Ferrer G (2006) Results of high bilateral endoscopic thoracic sympathectomy in the treatment of primary hyperhidrosis: a study of 1016 procedures. Arch Bronconeumol 42:230–234
Doolabh N, Horswell S, Williams M, Huber L, Prince S, Meyer DM, Mack MJ (2004) Thoracoscopic sympathectomy for hyperhidrosis: indications and results. Ann Thorac Surg. 77:410–414 (discussion 414)
Neumayer C, Zacherl J, Holak G, Függer R, Jakesz R, Herbst F, Bischof G (2004) Limited endoscopic thoracic sympathetic block for hyperhidrosis of the upper limb: reduction of compensatory sweating by clipping T4. Surg Endosc 18:152–156
Baumgartner FJ (2008) Surgical approaches and techniques in the management of severe hyperhidrosis. Thorac Surg Clin 18:167–181
Menezes R, Ribas J, Wen D, Loureiro MP, Furian MB, Costa MG, Coelho MS (2008) Guidelines for the prevention, diagnosis and treatment of compensatory hyperhidrosis. J Bras Pneumol 24:967–977
Weksler B, Luketich JD, Shende MR (2008) Endoscopic thoracic sympathectomy: at what level should you perform surgery? Thorac Surg Clin 18:183–191
Chou SH, Kao EL, Lin CC, Chang YT, Huang MF (2006) The importance of classification in sympathetic surgery and a proposed mechanism for compensatory hyperhidrosis: experience with 464 cases. Surg Endosc 20:1749–1753
Kim do H, Hong YJ, Hwang JJ, Kim KD, Lee DY (2008) Topographical considerations under video-scope guidance in the T3, 4 levels sympathetic surgery. Eur J Cardiothorac Surg 33:786–789
Dumont P (2008) Side effects and complications of surgery for hyperhidrosis. Thoracic Surg Clin 18:193–207
Lin TS, Chou MC (2004) Treatment of palmar hyperhidrosis using needlescopic T2 sympathetic block by clipping: analysis of 102 cases. Int Surg 89:198–201
Reisfeld R, Nguyen R, Pnini A (2002) Endoscopic thoracic sympathectomy for hyperhidrosis: experience with both cauterization and clamping methods. Surg Laparosc Endosc Percutan Tech 12:255–267
Cerfolio RJ, De Campos JR, Bryant AS, Connery CP, Miller DL, DeCamp MM, McKenna RJ, Krasna MJ (2011) The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg 91:1642–1648
Kang CW, Choi SY, Moon SW, Cho DG, Kwon JB, Sim SB, Wang YP, Jo KH (2008) Short-term and intermediate-term results after unclipping: what happened to primary hyperhidrosis and truncal reflex sweating after unclipping in patients who underwent endoscopic thoracic sympathetic clamping? Surg Laparosc Endosc Percutan Tech 18:469–473
Witzel C, Rohde C, Brushart TM (2005) Pathway sampling by regenerating peripheral axons. J Comp Neurol 485:183–190
Krarup C, Archibald SJ, Madison RD (2002) Factors that influence peripheral nerve regeneration: an electrophysiological study of the monkey median nerve. Ann Neurol 51:69–81
Reisfeld R (2006) Sympathectomy for hyperhidrosis: should we place the clamps at T2–T3 or T3–T4? Clin Auton Res 16:384–389
Disclosures
Authors Jesus Loscertales, Miguel Congregado, Rafael Jimenez-Merchan, Gregorio Gallardo, Ana Trivino, Sergio Moreno, Beatriz Loscertales, and Hugo Galera-Ruiz have no conflicts of interest or financial ties to disclose.
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Loscertales, J., Congregado, M., Jimenez-Merchan, R. et al. Sympathetic chain clipping for hyperhidrosis is not a reversible procedure. Surg Endosc 26, 1258–1263 (2012). https://doi.org/10.1007/s00464-011-2023-4
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DOI: https://doi.org/10.1007/s00464-011-2023-4