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Severe pompholyx following endoscopic thoracic sympathectomy for palmar hyperhidrosis

Ладонный гипергидроз (повышенная потливость ладоней) - лечение повышенной потливости
Блашинг-синдром (стрессовое покраснение лица, эритрофобия)
Рефлекторная симпатическая дистрофия
Комплексный регионарный болевой синдром как вариант хронической нейропатической боли
Комплексный регионарный болевой синдром в травматологической практике
Severe pompholyx following endoscopic thoracic sympathectomy for palmar hyperhidrosis
Early complications of thoracic endoscopic sympathectomy: a prospective study of 940 procedures

Hiroshi Niinai*, Masashi Kawamoto and Osafumi Yuge

Department of Anesthesiology and Critical Care Medicine, Hiroshima University Hospital, 1מן Kasumi, Minami-ku, Hiroshima 734?, Japan

* Corresponding author. Tel.: +81㫪��? fax: +81㫪��?. (E-mail: niinai@hiroshima-u.ac.jp).

Received for publication April 29, 2004. Revision received June 17, 2004. Accepted for publication July 2, 2004.


Abstract


Endoscopic thoracic sympathectomy has become the preferred methodfor treating intractable palmar hyperhidrosis because of itssimplicity, though various complications have been reported.We report two patients suffered from severe palmar pompholyx-likeeczema following this procedure. One was successfully treatedwith topical and oral steroids, however, the other had a wavelikecontinuation of eczema disturbing her daily activities. We recommendthat every sympathectomy for hyperhidrosis should be performedafter receiving informed consent to the possibility of evenminor complications such as acute pompholyx that could negativelyaffect postoperative quality of life.


1. Introduction


Endoscopic thoracic sympathectomy (ETS), an operative treatmentfor palmar hyperhidrosis, has become a common procedure. AlthoughETS is very effective for reducing palmar sweating, it is knownthat such complications as pneumothorax, hemothorax, Horner’ssyndrome, and severe compensatory sweating should be carefullyavoided [1ן]. Pompholyx is a form of eczema on the palmsand soles, in which edema fluid accumulates to form visiblevesicles or bullae [4]. It is a common skin feature in patientswith palmar hyperhidrosis, however, there are no reports ofa patient that developed severe pompholyx following ETS.


2. Case description


2.1. Case 1
A 34-year-old man was admitted under a diagnosis of palmar hyperhidrosis.A physical examination and preoperative laboratory test resultswere within normal ranges. Under general anesthesia in a semi-sittingposition, following an 8-mm skin incision along the right axillaryregion, a needle for insufflation was inserted through the Th2/3intercostal space and 1.5l of carbon dioxide was used to establisha pneumothorax. After a resectoscope was inserted through thesame incision into the thoracic cage, we cut the sympathetictrunk on the surface of the Th2, Th3, and Th4 ribs using a diathermywith coagulation mode. We left two Kuntz fibers found on theTh3 rib. Next, on the left side, we cut the trunk on the surfaceof the Th2, Th3, and Th4 ribs in the same manner, and left twoKuntz fibers found on the Th3 and Th4 ribs. A prophylactic antibiotics(1g of cefazolin sodium) was infused during the operation. Thepatient recovered from general anesthesia uneventfully.

On postoperative day (POD) 1, oral antibiotics (cefaclor, 750mg/day)and analgesics (loxoprofen sodium, 180mg/day) were administeredroutinely. Sweating in the palms and axillary regions were significantlyreduced, and the effect of the operation was considered satisfactory.On POD 3, a form of eczema of the palms along with severe itchingwas observed and diagnosed as pompholyx-like eczema (Fig. 1),which was different clinically from drug allergy. A steroidointment (0.1% mometasone furoate) and oral steroid (betamethasone,1.5mg/day) were prescribed and the eczema decreased by POD 4.The patient was discharged on POD 5 and the oral steroid wastapered over a week period. On POD 12, we confirmed that theeczema had disappeared in our out-patient clinic.



Экземоподобные изменения кожи ладоней после симпатэктомии

Fig. 1 Pompholyx-like eczema seen in Case 1.


2.2. Case 2
A 29-year-old woman with a diagnosis of palmar hyperhidrosisexhibited no abnormal medical findings preoperatively. Underthe same procedures as used in Case 1, we cut the bilateralsympathetic trunks on the surface of the Th2 and Th3 ribs. Weleft three Kuntz fibers found on the right Th3 rib, as wellas two Kuntz fibers found on the left Th2 and Th3 ribs.

Following the procedure, her palms were dry and we consideredthe results to be satisfactory. On POD 3, small vesicles withitching and pain were found on the bilateral palms, which werediagnosed as pompholyx-like eczema. We started treatment witha steroid ointment and oral steroid, as in Case 1. The conditionseemed to improve and the patient was discharged from the hospitalon POD 5. On POD 9, she returned to us complaining of an attackof itching and pain on her palms. We continued the steroid ointmentand have been following the patient for more than 2 years sincethe operation. She still has a wavelike continuation of pompholyx-likeeczema that was initiated by ETS, which disturbs her daily activities.


3. Discussion


The cause of pompholyx is obscure, and its alternative name,dyshidrotic eczema, may refer to a supposed connection withsweat gland activity regulated by the sympathetic nervous system.One case report of unilateral ETS that decreased ipsilateralpalmar pompholyx implied that an alteration of sympathetic activityaffected the disease [5]. It was also reported that a reductionin sympathetic tone associated with positive airway pressureinduced remission of pompholyx in a patient with sleep apneasyndrome [6]. These suggest that alterations of sympathetictone could result in the healing of pompholyx. It was also shownthat sudomotor response to sympathoexcitatory stimuli followingETS could be modulated not only by the anatomical level of theinterrupted thoracic sympathetic trunk [7], but also by thegrade of interruption achieved with the procedure [8]. In thepresent patients, we speculated that a reduction of sympatheticactivity in the sweat glands of the palms following ETS inducedan irregular alteration in thoracic sympathetic domination,which resulted in the formation of pompholyx-like eczema. Wedo not think surgical technique employed for these patientsdirectly affected the complication. It was reported that effectivenessof ETS should not to be altered without removing nerve segmentof sympathetic trunk or cutting Kuntz fibers [9,10].

For the treatment of pompholyx, topical steroid treatment iseffective, while a course of oral steroids is indicated forsevere cases [4]. Generally, the attack subsides spontaneouslyand resolution with desquamation occurs within 2ן weeksin most patients, as in Case 1. Nevertheless, as in Case 2,recurrent attacks can cause a wavelike continuation of symptomsthat disturb daily activities. ETS for palmar hyperhidrosisis an operation to improve quality of life and is not a treatmentfor a life threatening diseases. Therefore, full disclosureabout the procedure and its potential side effects must be givento patients, who otherwise may regret undergoing ETS, even thoughcessation of palmar sweating has been obtained.

We recommend that every ETS for hyperhidrosis should be performedfollowing careful evaluation of patient condition and afterreceiving informed consent to the possibility of even minorcomplications such as acute pompholyx that could negativelyaffect postoperative quality of life.

doi:10.1016/j.icvts.2004.07.001


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