T3-T4 Gray Sympathycotomy Versus Ramicotomy for Hyperhidrosis
Condition: Hyperhidrosis; Compensatory Sweating; Compensatory Hyperhidrosis
MeSH terms: Hyperhidrosis
Study type: Interventional

Summary: 
      It is presented a further refinement in palmar hyperhidrosis's surgical treatment to improve
      results and reduce side effects, mainly compensatory hyperhidrosis. It seems that a more
      selective sympathetic system lesion, namely a selective T3 and T4 gray rami communicantes
      lesion, allows retaining some residual sweating in the hands without inducing compensatory
      sweating in the abdomen, thighs, and feet. The result is greater patient satisfaction. There
      has been a long journey since Wittmosser et al. suggested the technique of gray and white
      ramicotomy in 1992. In this way, the attending physicians have refined the surgical procedure
      progressively. The two last research groups reporting their results with selective gray
      ramicotomy (the idea now is not to lesion the white rami communicantes) entailed extensive
      lesions (T2 to T4/T5). This study shows that a more selective T3 and T4 selective gray
      ramicotomy achieves excellent results with fewer side effects. Thus, it is a further step
      toward improving outcomes, reducing side effects, and increasing patients' satisfaction.

      Additionally, the present work has concentrated on objective ways to measure compensatory
      hyperhidrosis by measuring the sweat production in milliliters of water and the temperature
      changes in degrees Celsius. This accurate measurement removes the subjectivity induced when
      we base the results on the treating physicians' opinions or the patients themselves.

      The objective measurement of the sweat production in milliliters of water and temperature
      rise in degrees Celsius has allowed the research group to reach conclusions independent of
      opinions both from treating physicians and patients themselves. Also, a more selective gray
      rami communicantes lesion can achieve better results with less compensatory hyperhidrosis and
      with better patient's satisfaction
    

Detailed description: 
      Ever since the introduction of thoracic sympathectomy in the treatment of palmar and axillary
      hyperhidrosis, there has been a continuous quest to find a way to reduce its most unpleasant
      side effect: compensatory hyperhidrosis (CH). Following the idea of minimizing the surgically
      induced damage to the sympathetic chain, Wittmoser introduced in 1992, the ramicotomy
      technique. It entailed the selective lesion of the rami communicantes, both white and gray,
      from T2 to T4-T5. This surgical technique was not as selective as expected because it damaged
      the sympathetic input for the lungs and heart, and the head and face. Wittmoser described
      this surgical technique but never published any results. Gossot4 in 1997 compared this
      technique with the sympathectomy of the same ganglia in 54 patients. He found that CH's
      incidence was the same in both groups, but the severity was less in the ramicotomy than in
      the sympathectomy group. The recurrence rate was more prominent in the first than in the
      second group (5% ramicotomy versus 0% sympathectomy). Other researchers have confirmed these
      results.

      More studies compared the sympathectomy with the ramicotomy in the following years,
      confirming that ramicotomy has a lower incidence of CH5-10, with less dry hands but with some
      recurrences.

      In a step forward, Coveliers et al.11 lesioned only the T2 T3 and T4 gray rami communicantes,
      not touching the sympathetic chain or the white rami communicantes, with CH dropping to 7.2%
      and no recurrences. Akil et al.12 reported the lesion of the T2-T5 gray rami communicantes
      with no CH and again with no recurrences. Both studies entail a more extensive lesion,
      including T2, and one of those studies, T5. There is an agreement to avoid lesioning T2 in
      many previous reports to reduce the incidence and severity of CH.
    

Intervention name(s): Ramicotomy
Intervention type(s): Procedure
Intervention description(s): We will selectively lesion the gray rami communicantes from T3 and T4 thoracic sympathetic ganglia
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Two groups. One with T3-T4 sympathicotomy and another with T3-T4 gray ramicotomy
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Hyperhidrosis; Ramicotomy; Sympathectomy; Sympathicotomy; Compensatory hyperhidrosis; Gustatory sweating