Thoracoscopic Sympathetic Chain Interruption for Palmar Hyperhidrosis in Patients Below 18
Condition: Hyperhidrosis; Children, Adolescents; Thoracoscopic Sympathetic Chain Interruption; Sympathetic Disorder
MeSH terms: Hyperhidrosis
Study type: Interventional

Summary: 
      In this study, the investigators aim to present fifteen years' experience of thoracoscopic
      sympathetic chain interruption for primary palmar hyperhidrosis in children and adolescents;
      evaluation of 3 different techniques (sympathectomy, sympathotomy, and clipping) regarding
      demographic data, surgical outcomes, complications, compensatory sweating, and patients'
      satisfaction.
    

Detailed description: 
      Primary palmar hyperhidrosis (PPH) is a severely devastating autonomic disorder that can
      affect any patient regardless age, even pediatrics. Thoracoscopic sympathetic chain
      interruption offers a definitive effective therapy. In this study, the investigators aim to
      assess the outcomes of thoracoscopic management of palmar hyperhidrosis in a large cohort of
      children younger than 18 years old with severe PPH, using sympathetic chain interruption
      either by sympathectomy, sympathotomy or clipping, to provide a methodology focused on the
      long-term outcomes of those procedures.

      Patients and Methods: This is a retrospective study that included all children who underwent
      thoracoscopic sympathectomy, sympathotomy, or clipping for severe PPH, from April 2008 to
      March 2023 were assessed retrospectively. Demographic data, postoperative outcome,
      complications, compensatory sweating and satisfaction were analyzed.

      Surgical procedures:

      General anesthesia was used, with an ordinary endotracheal tube, by an experienced
      anesthesiologist who used one lung ventilation anesthesia to control the patient's
      O2-enriched ventilation in a low-volume/high-frequency technique, with alternating brief
      periods of apnea. The patient was placed in the semi-Fowler position, which is the dorsal
      decubitus position with the arms abducted and fixed at 90 degrees. The trunk was elevated by
      30-40 degrees; as elevation helped displace the lungs downwards. A slight bed elevation at
      the knee level was useful to safely place the patients and prevent them from slipping down
      during the procedure.

      To access the thoracic cavity, the investigators used the two-port video thoracoscopy using
      two 5 mm ports via 2 mini-incisions. The camera (30º scope) port was placed laterally at the
      fourth or fifth intercostal space (depending on the age of the patient) just posterior to the
      anterior axillary fold created by the pectoralis major muscle. The second port (for
      electrocautery instrument (hook) was laterally inserted in the third/fourth intercostal space
      at the mid-axillary line as that approach provides excellent aesthetic results. A CO2
      pneumothorax pressure of 5-8 mmHg was used according to patient's age and body built. The
      posterior parietal pleura was incised just lateral to neck of 3rd rib and further dissected
      down to identify the thoracic sympathetic chain.

      A-Thoracoscopic sympathectomy: A segment of the thoracic sympathetic chain at the intended
      levels is resected using hook electrothermoablation.

      B-Thoracoscopic sympathotomy technique (VATS): The sympathetic chain is just cut at the
      desired levels without excision.

      C-Thoracoscopic clipping technique: Titanium clips are applied on the desired level without
      cutting. Then, after completion of the procedure, CO2 pneumothorax was deflated, permitting
      full lung inflation under vision, without need for chest tube placement, ports removal, and
      port-sites closure by absorbable sutures with full awake recovery from anesthesia. Post
      operative routine chest x-ray was done to detect any residual pneumothorax and to assess the
      location of clips in clipping group.

      Statistical Analysis:

      Data were collected, revised, coded, and entered to the Statistical Package for Social
      Science (SPSS), IBM, version 23. The qualitative data were presented as numbers and
      percentages, while the quantitative data were presented as means, standard deviations, and
      ranges when their distribution was found to be parametric. Independent t-test and Chi-square
      tests were used to compare both groups. The p-value was considered significant if < 0.05.

      Discussion: will explore the different treatment modalities for PPH in children and
      adolescents, mentioning the medical/conservative methods, then focusing on the surgical
      option, that is thoracoscopic sympathetic chain interruption, either by sympathectomy,
      sympathotomy, and clipping for almost permanent remedy of PPH in pediatric age group younger
      than 18 years old. Points of discussion will include demographic data, follow-up period,
      surgical outcomes and complications, compensatory sweating, and patients' satisfaction.. The
      results obtained will be compared among the 3 groups and also compared to the previously
      published articles.

      Finally, the investigators will conclude whether or not there is a better technique among the
      3 modalities that gives the best durable outcome with the least complications.
    

Intervention name(s): Thoracoscopic sympathectomy; Thoracoscopic sympathotomy; Thoracoscopic sympathetic chain clipping
Intervention type(s): Procedure; Procedure; Procedure
Intervention description(s): Medical file records of patients of both sexes, below 18 years of age, suffering from significant bilateral palmar hyperhidrosis, managed by thoracoscopic bilateral simultaneous sympathectomy.; Medical file records of patients of both sexes, below 18 years of age, suffering from significant bilateral palmar hyperhidrosis, who underwent thoracoscopic bilateral simultaneous sympathotomy.; Medical file records of patients of both sexes, below 18 years of age, suffering from significant bilateral palmar hyperhidrosis, treated by thoracoscopic bilateral simultaneous sympathetic chain clipping.
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Intervention model description: This retrospective study was conducted at the Department of pediatric surgery, Al-Azhar University Hospitals in the period from April 2008 to March 2023, involving patients of both sexes, below 18 years of age, suffering from severe bothersome bilateral palmar hyperhidrosis, managed by thoracoscopic bilateral simultaneous sympathetic chain interruption.
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Palmar hyperhidrosis;; Thoracoscopic sympathectomy;; Compensatory sweating;; Pediatrics,; Adolescents