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Anesth Analg 2005;100:269-276 © 2005 International Anesthesia Research Society doi: 10.1213/01.ANE.0000139934.15659.7F
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Abstract |
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The assessment of sympathetic denervation to the upper extremities during surgery for hyperhidrosis is essential in predicting postoperative outcome, particularly for endoscopic thoracic chain sympathotomy, a recently described, minimally destructive technique that minimizes postoperative compensatory hyperhidrosis. To test the hypothesis that skin blood flow (SkBF; laser Doppler flowmetry) provides a faster and more reliable indication of denervation than temperature (temp), we prospectively compared palmar SkBF and fingertip temp in 10 patients undergoing endoscopic thoracic chain sympathotomy for essential hyperhidrosis. From baseline to peak values, palmar SkBF (mean ± SEM) increased 273.3 ± 24.7 arbitrary units and 252.4 ± 30.1 arbitrary units, whereas temp increased 0.9°C ± 0.3°C and 1.5°C ± 0.6°C on the right and left, respectively. Upon effective sympathotomy of the right thoracic chain, the time to peak SkBF was 43 ± 13 s, whereas the time to peak temp was 277 ± 53 s (P < 0.001). On the left, the time to peak SkBF was 81 ± 14 s, and time to peak temp was 305 ± 34 s (P < 0.001). All patients considered the sympathotomy successful. We conclude that laser Doppler SkBF is superior to temp in temporal resolution for assessment of denervation during sympathotomy and that it provides a superior qualitative and quantitative adjunct to monitoring denervation.
IMPLICATIONS: Termed sympathotomy, endoscopic surgical disconnection of the sympathetic chain to the upper extremities is an effective therapy for people affected with excessive sweating of the hands. Success relies on intraoperative monitoring of denervation, which can be determined rapidly by monitoring skin blood flow with laser Doppler flowmetry.
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Introduction |
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Palmar hyperhidrosis (PH) is an idiopathic phenomenon characterized by excessive sweating of the palms. Refractory to local treatments and medications, severe cases perpetuate physical, professional, and social debilitation. In this setting, endoscopic transthoracic sympathetic chain disruption to the upper extremity has become the procedure of choice because of minimal perioperative morbidity and excellent, immediate postoperative results (1). Traditionally, surgical sympathectomies have consisted of excision or electrocautery ablation of the T2 and/or T3 sympathetic ganglion. Recently, our institution has modified this technique by preserving the ganglia and performing a simple chain disconnection between the T2 ganglion and the stellate ganglion. Termed sympathotomy, this procedure produces excellent result while clinically diminishing the chances of severe compensatory hyperhidrosis (1).
The intraoperative assessment of sympathetic denervation is essential in predicting postoperative anhidrosis. Intraoperative physiological monitoring can include palmar skin temperature (temp), fingertip temp, infrared thermography, and, most recently, cutaneous perfusion with laser Doppler flowmetry (LDF) (2–11). Because of technical ease and minimal cost, skin temp monitoring has been considered reliable, but temp changes can be variable and misleading, particularly when distal skin temp before sympathotomy is increased. Moreover, the less destructive sympathotomy may result in smaller temp changes than those seen with sympathectomy (1). These small temp changes may be difficult to interpret.
An early study of skin perfusion with LDF successfully predicted sympathetic blockade during a test dose of epidural anesthesia (12). More recently, LDF has been used to assess the efficacy of sympathetic denervation during endoscopic thoracic sympathectomy for PH (2–4,10,11). It has been suggested that measurement of skin blood flow (SkBF) via LDF may provide a more rapid and precise indicator of sympathetic denervation than the slower and less specific increase in fingertip temp (11). Because cutaneous sympathetic vasoconstrictor nerves are tonically active, sympathetic denervation should cause an immediate increase in SkBF that would be particularly marked in glabrous skin, such as the palm (13–15). This increase in SkBF leads to the increase in finger temp traditionally used as an index of effective sympathectomy.
In this context, the precise time advantage or temporal resolution of LDF over skin temp has not been quantified. Furthermore, there are no data regarding the temporal resolution of SkBF during the minimally destructive endoscopic thoracic sympathotomy. Therefore, the purpose of this study was to compare the temporal resolution of responses in LDF and skin temp during endoscopic thoracic sympathotomy for PH. We hypothesized that LDF would allow for more rapid real-time feedback to the surgeons and would be a more consistent indicator of surgical success for PH. Additionally, we compared LDF responses in glabrous palmar skin to those in nonglabrous forearm skin before, during, and after sympathotomy.
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Methods |
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This study was approved by the Mayo Clinic IRB. From May to October 2003, we prospectively studied 10 consecutive patients with a diagnosis of PH in whom medical therapy had failed. Patient characteristics are shown in Table 1. Before surgery, all patients reported excessive sweating of the hands and feet, either lifelong or since adolescence. A comprehensive neurologic examination including a thermoregulatory sweat test was used to verify the diagnosis of idiopathic primary hyperhidrosis. All patients had elected to proceed with bilateral endoscopic thoracic sympathotomy performed by one surgeon (JLDA). All patients were generally healthy and were ASA physical classification I (n = 8) or II (Patient 4, body mass index 39 kg/m2; Patient 8, asthma). Seven patients (Patients 1–6 and 10) were taking no regular medications. Patient 7 was taking zolpidem for insomnia. Patient 8 was taking cetirizine hydrochloride for seasonal allergies and inhaled fluticasone propionate/salmeterol xinafoate for well-controlled asthma. Patient 9 was taking hormone-replacement therapy and was taking digoxin for a remote history of paroxysmal atrial fibrillation (normal sinus rhythm on the day of surgery). All subjects were included because it was believed that these comorbidities or medication regimens would not significantly interfere with the study objective or data analysis.
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On the morning of surgery, informed consent was obtained. Upon arrival to the operating room, a peripheral IV was inserted in the dorsum of the hand or in the antecubital fossa, and standard monitors were applied. Heart rate was obtained by electrocardiogram, arterial blood pressure by oscillometric cuff on the calf or thigh, and pulse oximetry on the second toe of the contralateral foot. The induction of general anesthesia was performed IV with fentanyl (1 µg/kg), lidocaine (1 mg/kg), propofol (2 mg/kg), and vecuronium (0.1 mg/kg), and after placement of a double-lumen endotracheal tube, anesthesia and paralysis were maintained with isoflurane (0.5–1.5 expired percentage) and vecuronium (0.05 mg/kg). An esophageal temp probe was placed to monitor core temp, and insulated surface skin temp probes (400 Series Thermistor; SIMS Respiratory Support Products, Irvine, CA) were placed on the ventral fat pad of the index fingers bilaterally. SkBF was measured as LDF by using integrating LDF probes (Periflux System 5000; Perimed, Stockholm, Sweden) on bilateral palms and ventral forearms simultaneously. LDF probes were positioned centrally on the thenar eminence and at mid length of the ventral forearm, avoiding proximity to veins or IV catheters. LDF was sampled at 250 Hz and subsequently analyzed offline (WinDaq; Dataq Instruments, Akron, OH). All patients underwent identical bilateral sympathotomy with use of uniportal access amid one-lung ventilation as previously described (1). Immediately after surgery, one patient (Patient 6) developed a right pneumothorax. Angiocatheter decompression was performed, and the patient had an uneventful recovery. Because of intraoperative bleeding of a chest wall vein, Patient 8 received a right chest tube that was discontinued the following day.
To assess the temporal resolution of SkBF versus fingertip temp as intraoperative physiologic markers of sympathetic denervation, we defined SkBF values as follows. Baseline SkBF was defined as the SkBF at one probe (palm or forearm ipsilateral to concurrent sympathotomy) before an acute increase in SkBF after ipsilateral cautery. Peak SkBF was defined as the greatest SkBF value after cautery, at the onset of a sustainable plateau, with no further changes in SkBF. Time to peak SkBF was defined as the time, in seconds, from cautery to peak SkBF. SkBF 90 and SkBF 50 were reported as the SkBF values at 90% and 50% of the 
SkBF (peak – baseline SkBF). Thus, time to SkBF 90 and time to SkBF 50 were defined as the time between cautery and SkBF 90 and SkBF 50, respectively. Because baseline forearm SkBF was minimal and the responses to sympathotomy were modest, baseline forearm SkBF was reported as the average SkBF for 1 min before ipsilateral sympathotomy, and postsympathotomy SkBF was reported as the average SkBF over 5 min after the ipsilateral palmar peak SkBF. Temp values were defined in similar fashion. Peak temp was further defined as the temp value after electrocautery that was sustained for 1 min or when the surgeon was satisfied with the procedure and began closing the wound.
Each of the variables of SkBF and temp was averaged among all patients, and variables were compared by paired Student’s t-tests. Statistical significance was accepted for P < 0.05. Therapeutic outcomes were assessed up to 4 mo after the operative procedure. This consisted of a verbal interview and neurological evaluation. A voluntary thermoregulatory sweat test was encouraged but not mandated.
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Results |
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All 10 patients considered the sympathotomy successful and were pleased with the overall outcome on both sides (Table 1). Four patients participated in a postoperative thermoregulatory sweat test, which confirmed the success of the procedure. Seven patients reported diminished sweating of the feet. There were no cases of severe, or even moderate, compensatory hyperhidrosis. However, seven patients developed mild, nonbothersome compensatory hyperhidrosis of the trunk.
Figure 1 displays SkBF and temp for Patient 4 during right thoracic skin incision, right sympathotomy, left thoracic skin incision, and left sympathotomy. The initial right chest incision evoked bilateral sympathetically mediated reflex vasoconstriction and a gradual decrease in skin temp. Upon cautery of the right sympathetic chain, SkBF increased immediately, and temp followed more gradually. Importantly, both SkBF and temp on the right side remained increased during subsequent contralateral (left) chest incision and sympathotomy. After left incision, ipsilateral SkBF remained low, and temp continued to decrease (Fig. 1B). After left sympathetic chain cautery, SkBF increased rapidly on the left side, followed by temp.
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Figure 2 displays the actual LDF tracing during right sympathotomy in Patient 3. This is shown on an expanded time scale and represents an important variation we observed in the SkBF response to general anesthesia. In contrast to Patient 4 (Fig. 1), this patient displayed a marked vasodilator response to general anesthesia (high SkBF). Surgical manipulation caused reflex vasoconstriction, especially during probing of the sympathetic chain just before cautery, as shown. Sympathotomy blocked this sympathetically mediated vasoconstriction, causing immediate and sustained vasodilation. To characterize the rapidity of this inhibition, the baseline SkBF was thereby reported as the lowest SkBF level before an acute and sustainable increase in SkBF that was refractory to further stimulation of any kind.
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Table 2 depicts the average baseline SkBF, peak SkBF, baseline temp, peak temp, and
values. From baseline to peak values, the average palmar SkBF increased 273.3 ± 24.7 arbitrary units (AU) and 252.4 ± 30.1 AU on the right and left side, respectively. For fingertip temp, the average increase was 0.9°C ± 0.3°C and 1.5°C ± 0.6°C on the right and left, respectively. Importantly, 8 of the 20 sympathotomized limbs displayed a temp increase of <0.5°C. However, the average increase in SkBF for those eight limbs was 275.2 ± 31.3 AU and was easily detected with LDF monitoring.
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The temporal resolution of SkBF was greater than that of fingertip temp for all subjects, as illustrated in Table 3. Upon effective sympathotomy of the right thoracic chain, time to peak SkBF was 43 ± 13 s, and time to peak temp was 277 ± 53 s (P < 0.001). On the left side, time to peak SkBF was 81 ± 14 s, and time to peak temp was 305 ± 34 s (P < 0.001). Comparing the time to peak SkBF of the right and left side, there was a tendency for the SkBF response to be slower on the left side (P = 0.06). However, the
between SkBF and temp was similar on both sides (235 ± 42 s versus 224 ± 33 s on the right versus left, respectively).
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To further delineate the time course or rate of change between modalities, we also calculated the time at which SkBF and temp reached 50% and 90% of their respective peaks (temp 50 and 90, respectively). On the right side, time to SkBF 90 was 34 ± 13 s, and time to temp 90 was 229 ± 43 s (P < 0.001). On the left side, time to SkBF 90 was 58 ± 13 s, and time to temp 90 was 247 ± 32 s (P < 0.001). For the 50% values after sympathotomy of the right thoracic chain, time to SkBF 50 was 6 ± 1 s, and time to temp 50 was 144 ± 36 s (P < 0.004). On the left side, time to SkBF 50 was 17 ± 7 s, and time to temp 50 was 150 ± 29 s (P < 0.002).
Finally, forearm SkBF did not demonstrate consistent changes during surgery. Right forearm SkBF was 22.8 ± 6 AU at baseline and was 23.9 ± 7 AU after sympathotomy. On the left, forearm SkBF was 21.5 ± 3 AU at baseline and was 22.8 ± 3 AU after sympathotomy (P > 0.4 for both).
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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The major new finding of this study was that SkBF (measured by LDF) provides a substantially more rapid indication of successful sympathotomy compared with measurement of fingertip temp. Furthermore, the lack of reflex vasoconstriction to surgical stimulation detectable by LDF rapidly confirms effective denervation, potentially providing a more reliable predictor of surgical outcome. Another new finding is that forearm SkBF does not change consistently during sympathotomy and is therefore not a useful indicator of successful sympathetic denervation.
The average intraoperative fingertip temp increase of 1.2°C with sympathotomy in our study is less than the skin temp increase of approximately 3°C reported with more destructive procedures (4,9,16). This has important implications in the choice of intraoperative monitoring techniques, because smaller changes in temp, when considered alone, might raise doubt as to the procedure’s therapeutic efficacy. Another limitation of solely monitoring temp changes during sympathotomy or sympathectomy is that temp regulation is altered during general anesthesia. Anesthetics reduce tonic cutaneous vasoconstriction in the skin, and this results in passive vasodilation and a redistribution of heat from the core to the periphery (17). The subsequent decline in core body temp may produce a lower temp gradient between the core and the periphery, thus contributing to modest temp changes after effective denervation. This may have contributed to the observation in this study that 8 of 20 limbs had a temp increase of 
0.5°C.
Our findings are consistent with a recent study with palmar LDF during sympathectomy ablation of the T2 and T3 ganglia, which demonstrated that the numeric increases were correlated with surgical outcome at six months after surgery (11). We characterized the temporal resolution of SkBF responses and the importance of qualitative interpretation of beat-to-beat changes in SkBF throughout the procedure. We noted that SkBF decreased rapidly in response to surgical stimulation and typically remained slow throughout stimulation until effective sympathotomy on the first side. Subsequently, SkBF on the sympathotomized palm remained maximal and unaffected by further stimulation in the procedure, including incision and cautery on the contralateral side. This lack of reflex vasoconstriction helped to confirm the therapeutic efficacy of the procedure.
In support of our hypothesis, fingertip temp changes were slower and more modest in terms of absolute changes from baseline. Overall, this highlights the nonlinear relationship between SkBF and skin temp and suggests that, in addition to temporal resolution, SkBF monitoring is both qualitatively and quantitatively superior to temp monitoring during sympathotomy. This may also have broad implications from an economic standpoint. At first glance, the speed of LDF over temp appears to reduce operative time by three minutes per side (six minutes per operation). However, the real-time feedback of LDF enables the surgeon to identify the chain with manual stimulation and to determine an immediate response to electrocautery at that site. Without LDF, if the surgeon had expected a temp increase of 1°C per side, 13 of 20 sympathotomies in this study would have required more time and, potentially, more surgical exploration. Most importantly, the synergism of these techniques should eliminate or drastically reduce surgical failure and the need for reoperation. Since completion of this study, our institution has purchased equipment dedicated to routine use in this procedure.
Our observation of changes in SkBF in the palm, and a relative lack of change in the forearm, is consistent with the known physiology of the neural control of the human cutaneous circulation. In glabrous skin (palms, soles, and lips), low-resistance arteriovenous anastomoses (AVAs) are numerous and richly innervated by sympathetic vasoconstrictor nerves (14). Thus, opening or closing of these AVAs by changes in sympathetic activity can cause substantial changes in SkBF (13). This likely explains the immediate large changes in palmar SkBF observed during sympathetic denervation in this study. Nonglabrous skin, in contrast, has very few, if any, AVAs (14,18). Because interruption of vasoconstrictor nerves in forearm (nonglabrous) skin causes only approximately 10%–20% of its capacity for vasodilation (14,19), our ability to observe this small change (in combination with the vasodilator effect of anesthesia) was limited.
It deserves mention that neither temp nor SkBF is a direct measure of sudomotor function or neural disconnection. Skin sympathetic nerve activity includes vasoconstrictor, vasodilator, sudomotor, and piloerector nerves (14,15). It can only be assumed that abrupt inhibition of cutaneous sympathetic vasoconstriction during sympathotomy is representative of the disconnection of sudomotor innervation as well. Interestingly, although forearm blood flow studies have shown that baroreflex-mediated vasoconstriction during incremental lower body negative pressure is absent in patients months to years after sympathectomy, endothelial and vascular smooth muscle function is preserved (20). Normalization of upper extremity vasomotor regulation in the setting of chronic anhidrosis is a favorable outcome (21), but the mechanism is poorly understood.
A thermoregulatory sweat test was not performed in all patients. A unique feature of this surgical therapy is that successful outcome is based on patient satisfaction. In the original description of this procedure (1), some minor sweating occurred during the sweat test in 40% of limbs after sympathotomy. Nonetheless, 100% of patients reported subjective satisfaction with the procedure. Because of this, we believed that an acceptable outcome measure did not require a thermoregulatory sweat test, but it was encouraged on a voluntary basis. Admittedly, the long-term durability of the procedure (reduced sweating) requires further follow-up.
In this edition of Anesthesia & Analgesia, Crandall et al. (22) report SkBF and temp comparisons during traditional thoracic sympathectomy, including excision of the T2 ganglia. Our observations and those of Crandall et al. share the major similarity that measurement of SkBF consistently provided greater temporal resolution to measurement of temp with regard to confirmation of successful sympathectomy. An interesting difference between the two studies was that the overall response times in both SkBF and temp were substantially longer in their study than in ours. This difference may have been due to the difference in surgical approach between studies. Importantly, the consistent finding of greater temporal resolution with LDF of SkBF across two different surgical approaches lends further support to our conclusion that intraoperative monitoring of SkBF with LDF improves the ability to rapidly confirm successful interruption of sympathetic innervation.
In conclusion, this study provides novel quantitative evidence that LDF provides an excellent and rapid indication of sympathetic denervation during endoscopic thoracic sympathotomy for hyperhidrosis. Furthermore, the use of a less destructive sympathotomy in attempt to reduce postoperative compensatory hyperhidrosis encourages the use of this more sensitive monitoring technique as an adjunct to skin temp, because skin temp changes are often relatively small. Finally, by comparing SkBF of the palms and forearms, we also demonstrated that monitoring nonglabrous skin provides little information regarding the efficacy of sympathotomy.
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Acknowledgments |
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Supported by National Institutes of Health Grant K23 RR017520-01.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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- Atkinson JL, Fealey RD. Sympathotomy instead of sympathectomy for palmar hyperhidrosis: minimizing postoperative compensatory hyperhidrosis. Mayo Clin Proc 2003; 78: 167–72.
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