Novel Treatment of Palmar Hyperhidrosis With Robotic Hybrid Cryoablation Sympathectomy

Introduction

Primary (focal) hyperhidrosis is a condition of excessive sweating wherein sweat gland function exceeds the need to cool the body. It often affects the axilla, face, palms, or soles and can create a substantial burden on personal hygiene, work and productivity, self-esteem, and emotional well-being. ¹ Treatment of palmar hyperhidrosis is approached in a stepwise fashion, with first-line therapies including aluminum chloride antiperspirants, iontophoresis, and botulinum toxin injections. For those who have failed or are intolerant to nonsurgical therapies, endoscopic thoracic sympathectomy (ETS) can be considered. ¹ The most common and dreaded complication of sympathectomy is compensatory hyperhidrosis (CH), which can range from mild to severe, further compromising quality of life and causing some to regret having surgery. ² We present a novel hybrid approach combining ETS with sympathetic chain cryoablation in a patient with severe palmar hyperhidrosis (Supplemental Video). Written consent was obtained from the patient approving the use of their data for publication of this report.

Case Report

A 21-year-old healthy female patient presented with lifelong hyperhidrosis of her hands and, to a lesser extent, feet and posterior thighs. She endured significant barriers to performing functions of daily life, including difficulty keeping papers dry and usable at school, inability to effectively grasp and grip objects such as pencils and doorknobs, problems wearing gloves for lab safety at work, and psychological reticence to shake hands with others. Comprehensive medical evaluation ruled out secondary causes for her symptoms. Her care was transitioned to a local plastic surgeon for nonsurgical therapies, including antiperspirants and chemical denervation of bilateral hands using botulinum toxin (Botox^®, Allergan, Inc., Dublin, Ireland). She developed chemical burns with topical treatments. Botox treatments effectively reduced palmar moisture but had diminishing clinical benefit and duration of effectiveness with each successive treatment. She was subsequently referred to our thoracic surgery clinic for consideration of sympathectomy. A lengthy discussion was held with the patient regarding surgical options, focusing on the potential consequences of CH. Her goal was expressly to achieve a functional level of palmar dryness, and she was willing to accept some degree of CH for this result. Temporary alternatives, including sympathetic chain clipping and local anesthetic blockade, were also included in the discussion as was the possibility of reoperative intervention for failed sympathectomy or conversion of a temporary blockade to permanent sympathectomy. Ultimately, shared decision-making resulted in a plan for R4 sympathectomy with cryoablation of R3 as an approach to “trial” the body’s response to R3+R4 interruption. In the event of severe CH, the effects of cryoablation on R3 would likely be temporary. If desired, R3 sympathectomy could then be considered for recurrence of palmar sweating or unacceptable levels of palmar dryness without the uncertainty of CH. This was an off-label use of cryoablation that had not been previously described and was thus considered experimental. Furthermore, because the cryoablative technology was designed explicitly for use on intercostal nerves, no assurance could be made of the reversibility of cryoablation on the sympathetic chain. The patient consented to the procedure, and surgery was scheduled at the end of the school year.

The patient was positioned supine under general anesthesia with a left-sided double-lumen endotracheal tube. Ports were placed in the third, fourth, and fifth intercostal spaces anteriorly, and the da Vinci^® Xi robotic system (Intuitive Surgical, Sunnyvale, CA, USA) was docked. Rib spaces were counted and marked to identify the appropriate levels. The sympathetic chain was exposed and mobilized circumferentially from the third to fifth rib. The intervening segment of the chain was divided from the top of the fourth rib to the top of the fifth rib with bipolar cautery (Fig. 1), and the segment was sent to pathology for frozen section confirmation of neural tissue. The cryoSPHERE™ cryo nerve block probe (AtriCure Inc., Mason, OH, USA) was then applied directly over the nerve at the bottom of the third rib, and freezing commenced to −65 °C for a total of 120 s, followed by active defrosting (Fig. 2). Intercostal nerve block using liposomal bupivacaine (Exparel^®) and intercostal nerve cryoablation of T3 to T6 using the same probe were also performed to optimize postoperative pain control. The entire procedure was then repeated on the left side. The right-hand temperature increased by 1 °C, and the left-hand temperature increased by 0.8 °C at the conclusion of the procedure. Bilateral 24-french silicone drains were placed at the end of surgery and removed in the postanesthesia care unit once chest x-ray confirmed complete lung reexpansion. The patient had an uneventful postoperative course, without palmar or truncal sweating, and was discharged home on postoperative day 1.

Fig. 1.

Dissection and exposure of the sympathetic chain from the top of the third rib to the top of the fifth rib. R4 sympathectomy shown within red circle.

Fig. 2.

Cryoablation of the sympathetic chain at the bottom of the third rib (R3) using the cryoSPHERE™ probe (AtriCure Inc., Mason, OH, USA). Excised R4 segment shown between the white lines.

At 2-week follow-up, palmar sweating was minimal, but the patient endorsed mild plantar and groin CH. Three months later, she reported complete resolution of palmar hyperhidrosis as well as restoration of baseline plantar and groin sweating. One year later, she continued to experience dry palms and was very satisfied with the results. Her plantar and groin sweating had returned to preoperative baseline and were not particularly bothersome. Her quality of life had greatly improved. She did not desire to pursue R3 sympathectomy.

Discussion

The optimal surgical therapy for primary hyperhidrosis remains controversial. Sympathectomy or ganglionectomy, which refers to total ablation or removal of a segment of the sympathetic chain and/or ganglia, is the mainstay of surgical treatment for appropriately selected candidates. ³ Other surgical techniques used for interruption, including clipping, cutting, and cauterizing the sympathetic chain at various levels from R2 to R4, have also been described. ¹ The most common and potentially regrettable side effect of these procedures is CH, with a reported incidence ranging from 3% to 98%. ³ In general, the higher the level of interruption along the chain, the higher the expected “regret rate.” ² In patients who desire complete palmer dryness and are willing to accept a higher CH risk, R3+R4 interruption can reasonably be offered. However, based on prospective randomized studies comparing R3 versus R4 interruption, isolated R4 interruption can produce acceptable levels of palmar dryness with lower risk and degree of CH. ⁴ In an effort to predict and prevent permanent postsympathetic CH, some groups have described temporary sympathetic blockade employing clips and local anesthetic injections.^2,5 Despite initial optimism for clipping, clip removal may not be as reversible as previously thought due to irreversible perineural damage of the nerve. ⁵ In addition, although sympathetic blockade with local anesthetic is fully reversible, its effects are transient, requiring a second operation to perform sympathectomy.

Our hybrid technique exploits the effectiveness and low CH risk of R4 sympathectomy with the reversibility of R3 cryoablation to predict the effects of an R3+R4 sympathectomy. Reversion to an R4 sympathectomy state is expected once neurolysis of R3 resolves (approximately 3 months). In the event of recurrent severe hyperhidrosis following neural regeneration, return to the operating room for formal R3 sympathectomy could be considered without concern for permanent, disabling CH. With the excellent visualization and tissue handling afforded by the robotic platform, reoperative identification and dissection of the residual R3 segment was expected to be relatively straightforward.

Our case highlights the feasibility and benefits of a hybrid cryoablation sympathectomy in the management of severe palmar hyperhidrosis. Further investigation in a controlled setting would be needed to confirm our results and explore potential applications to other distributions of sweating.